Rancho Level IV — the agitated week
| Patient | 45F, subacute phase |
|---|---|
| Injuryright temporal contusion with a small subdural collection | |
| Severity | Worst GCS 10 |
| Days since injury | 10 |
| Before the injuryIndependent. Teaches primary school; fell painting a ceiling. | |
| PrecautionsFall risk — unprompted standing; low bed, enclosed therapy space; Post-traumatic amnesia — no unsupervised mobility; Line-pulling — monitor and cover access sites | |
Test yourself
What is the safest mobility intervention this week?
The teaching
Rancho Level IV is the week the environment does the treating. The post-traumatic amnesia guidance is consistent: structure, low stimulation, consistent handlers, and no restraint for anything short of danger. Clearance is declared on measurement — a standardized daily orientation score holding normal across consecutive days — not on a good afternoon. What you do with it: prescribe mat-based movement in a closed room, coach the family into short structured visits, and let the GOAT, not the FIM, call the end of PTA.
- Agitation with new drowsiness, worsening headache or a new deficit — re-image, this may be the collection growing
- Self-harm or harm to staff that structure cannot contain — escalate, do not improvise restraint
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Ponsford J et al. INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury, part I: posttraumatic amnesia. J Head Trauma Rehabil. 2023. Hagen C. The Rancho levels of cognitive functioning: the revised levels. Professional Staff Association of Rancho Los Amigos Medical Center. 1998 · Ponsford J et al. INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury, part I: posttraumatic amnesia. J Head Trauma Rehabil. 2023. Bayley MT et al. INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury. J Head Trauma Rehabil. 2023 · Levin HS et al. The Galveston Orientation and Amnesia Test: a practical scale to assess cognition after head injury. J Nerv Ment Dis. 1979. Ponsford J et al. INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury, part I: posttraumatic amnesia. J Head Trauma Rehabil. 2023