A 36-year-old woman comes to the office after a month of almost daily, bandlike headaches, dizziness, and fatigue. She has experienced irritability, inability to concentrate, and poor sleep of the same duration. Prior to the onset, she had an accident at work; a box fell on her head, and she lost consciousness briefly. The patient was taken to an emergency department and all tests were normal, so she was discharged. She has had no nightmares or flashbacks of the event. She has no known medical problems. She drinks 1-2 glasses of wine every evening but does not use tobacco or illicit drugs. The patient is afebrile. Blood pressure is 125/85 mm Hg and pulse is 76/min. Cardiopulmonary and abdominal examinations are unremarkable. She appears anxious but her neurologic evaluation including attention and memory is normal. Which of the following is the most likely diagnosis?

Question

A 36-year-old woman comes to the office after a month of almost daily, bandlike headaches, dizziness, and fatigue.  She has experienced irritability, inability to concentrate, and poor sleep of the same duration.  Prior to the onset, she had an accident at work; a box fell on her head, and she lost consciousness briefly.  The patient was taken to an emergency department and all tests were normal, so she was discharged.  She has had no nightmares or flashbacks of the event.  She has no known medical problems.  She drinks 1-2 glasses of wine every evening but does not use tobacco or illicit drugs.  The patient is afebrile.  Blood pressure is 125/85 mm Hg and pulse is 76/min.  Cardiopulmonary and abdominal examinations are unremarkable.  She appears anxious but her neurologic evaluation including attention and memory is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient is showing signs of postconcussive syndrome following a mild traumatic brain injury (TBI). TBI of any severity can lead to (a few hours or days later) postconcussive syndrome, which is clinically described by the following constellation of symptoms: headache, confusion, amnesia, difficulty concentrating or with multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. Typically, these symptoms resolve with symptomatic treatment within a few weeks to months following TBI; however, some patients may have persistent symptoms lasting >6 months. > (Choice A) Acute stress disorder develops following exposure to threatened death, serious injury, or sexual violation and is characterized by intrusive memories, nightmares, flashbacks, avoidance, and arousal symptoms (eg, hypervigilance, insomnia, irritability, poor concentration). Symptoms last 3 days to 1 month. Although acute stress disorder symptoms overlap with those of TBI, the type of trauma, prominent physical symptoms, and lack of nightmares or flashbacks in this patient make TBI more likely. (Choice B) Delayed subdural hematoma will typically present with focal neurologic deficits (eg, hemiparesis, slurred speech, aphasia, gait disturbance, hemianesthesia). (Choice C) In factitious disorder, the individual purposely feigns physical or psychological symptoms to meet emotional needs. Obvious external rewards are absent. (Choice D) Korsakoff syndrome (KS) is described as an acute onset of severe memory impairment that occurs in the setting of thiamine (vitamin B₁) deficiency and is commonly seen in alcoholic patients. KS may occur concurrently with or following the development of Wernicke encephalopathy (late phase), which is also caused by thiamine deficiency (early phase) and characterized by the presence of ocular disturbances, alteration of consciousness, and ataxia. (Choice F) Post-traumatic stress disorder develops after exposure to emotionally traumatic events and is characterized by reexperiencing the trauma (flashbacks, nightmares) and avoidance and arousal symptoms. Symptoms persist for >1 month. (Choice G) Somatic symptom disorder involves excessive preoccupation with >1 medically unexplained somatic symptom for >6 months that causes significant social and occupational impairment. > > Educational objective: Traumatic brain injury (TBI) of any severity can lead to (a few hours to days later) postconcussive syndrome, which is clinically described by the following constellation of symptoms: headache, confusion, amnesia, difficulty concentrating or with multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. These symptoms typically resolve with symptomatic treatment within a few weeks to months following TBI; however, some patients may have persistent symptoms lasting >6 months. > References: Diagnosis of mild head injury and the postconcussion syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/10739967)

A 36-Year-Old Woman Comes to the Office After a Month