A 16-year-old previously healthy boy is brought to the emergency department 30 minutes after a head injury. He was playing football when he had a helmet-to-helmet impact with another player. The patient was dazed and disoriented for several minutes after the incident but did not lose consciousness. He stumbled and fell after getting up. The patient is now awake and alert and reports mild headache but no nausea, vision changes, or other subjective neurologic deficits. Vital signs are within normal limits. On physical examination, he appears tired. There is no obvious head deformity. The pupils are equal and reactive, and there is no facial droop. Bilateral upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal. Which of the following is the most likely cause of this patient's symptoms?

Question

A 16-year-old previously healthy boy is brought to the emergency department 30 minutes after a head injury.  He was playing football when he had a helmet-to-helmet impact with another player.  The patient was dazed and disoriented for several minutes after the incident but did not lose consciousness.  He stumbled and fell after getting up.  The patient is now awake and alert and reports mild headache but no nausea, vision changes, or other subjective neurologic deficits.  Vital signs are within normal limits.  On physical examination, he appears tired.  There is no obvious head deformity.  The pupils are equal and reactive, and there is no facial droop.  Bilateral upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d5a0_939e_bc81_bf258c5d87f7_MD0003_00 This patient who developed disorientation after a head injury but does not have sustained neurologic deficits likely has a concussion, a form of mild traumatic brain injury. Head trauma (typically due to blunt force) can cause widespread neuron depolarization, decreased cerebral blood flow, and localized lactic acidosis, which leads to transient disturbance of normal neuronal function. Typical symptoms of concussion are headache, dizziness, disorientation, and/or amnesia, which may be retrograde or anterograde. Other common symptoms may include transient abnormalities in coordination (eg, stumbling, falls), speech (eg, slurring), attention (eg, poor focus), or emotion (eg, lability). Vomiting and loss of consciousness may also occur. Focal neurologic deficits, depressed or worsening mental status, or signs of possible skull fracture (eg, battle sign, temporal hematoma) are atypical and should prompt further evaluation with a head CT scan. (Choice A) Diffuse axonal injury occurs with tearing of the white matter tracts. It typically occurs with severe trauma (ie, shaken baby syndrome, head impact during car collision), and patients are severely obtunded or comatose. (Choice B) Basilar skull fracture typically presents with battle sign (ie, bruising behind the ears) or racoon eyes (ie, periorbital bruising) and may be complicated by cerebrospinal fluid leak, which can cause clear rhinorrhea. (Choice D) Epidural hematoma is most commonly caused by rupture of the middle meningeal artery due to fracture of the temporal bone. A temporal hematoma is often present, and patients frequently experience a transient loss of consciousness followed by a lucid interval before declining to coma. (Choice E) Subdural hematoma is caused by tearing of the bridging veins. Traumatic subdural hematoma usually presents with coma at the time of injury; those who remain lucid typically develop vomiting, cranial nerve palsies, and ataxia before declining to coma. Educational objective: Concussion is a form of mild traumatic brain injury resulting in transient impairment of normal neuronal function. Typical symptoms include headache, disorientation, dizziness, and/or amnesia associated with abnormalities in coordination, speech, attention, or emotions.

A 16-Year-Old Previously Healthy Boy Is Brought to the Emergency