A 28-year-old previously healthy man comes to the office with his girlfriend after having intermittent headaches, dizziness, and fatigue for the last several weeks. He has also had insomnia and trouble concentrating. She reports that he is irritable, argumentative, and very sensitive to noise. The patient was involved in a fight 6 weeks ago during which he was hit on the head and "blacked out" for a few minutes. According to his girlfriend, he consumes several hard drinks over the weekend but rarely drinks "in excess." His blood pressure is 130/80 mm Hg and pulse is 76/min. Cardiopulmonary examination is unremarkable. Muscle power is 5/5 in the bilateral upper and lower extremities, sensation is intact, and reflexes are 2+ throughout. The patient is oriented and has normal memory but is anxious. His hemoglobin is 14.2 gm/dL, creatinine is 0.8 mg/dL, and liver function tests are normal. MRI of the head is normal. Urine toxicology screen is positive for cannabinoids but negative for cocaine and opioids. Which of the following is the most likely diagnosis?

Question

A 28-year-old previously healthy man comes to the office with his girlfriend after having intermittent headaches, dizziness, and fatigue for the last several weeks.  He has also had insomnia and trouble concentrating.  She reports that he is irritable, argumentative, and very sensitive to noise.  The patient was involved in a fight 6 weeks ago during which he was hit on the head and "blacked out" for a few minutes.  According to his girlfriend, he consumes several hard drinks over the weekend but rarely drinks "in excess."  His blood pressure is 130/80 mm Hg and pulse is 76/min.  Cardiopulmonary examination is unremarkable.  Muscle power is 5/5 in the bilateral upper and lower extremities, sensation is intact, and reflexes are 2+ throughout.  The patient is oriented and has normal memory but is anxious.  His hemoglobin is 14.2 gm/dL, creatinine is 0.8 mg/dL, and liver function tests are normal.  MRI of the head is normal.  Urine toxicology screen is positive for cannabinoids but negative for cocaine and opioids.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 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 to days later) postconcussive syndrome, which includes the following constellation of symptoms: headache, confusion, amnesia, difficulty in concentrating or with multitasking, vertigo, hypersensitivity to various stimuli, 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. (Choice A) This patient does not appear to drink alcohol excessively based on his social history and laboratory studies. Given his relatively recent history of head trauma, postconcussive syndrome is a more likely diagnosis than alcohol intoxication. (Choice B) Cannabis withdrawal involves at least 1 physiological symptom (eg, abdominal pain, sweating, shakiness, fever, chills, headache) and 2 or more of the following symptoms developing after cessation of heavy and prolonged use: Irritability, anxiety, insomnia, decreased appetite, restlessness, depressed mood. Given that cannabis was found on this patient's urine toxicology screen, withdrawal from this drug is less likely. (Choice C) Generalized anxiety disorder is characterized by excessive anxiety and worry about multiple issues for >6 months. Although difficulty in concentrating, irritability, sleep disturbance, and fatigue are symptoms of generalized anxiety disorder, this patient's history of head trauma and shorter duration of symptoms make postconcussive syndrome more likely. (Choice E) Post-traumatic stress disorder (PTSD) develops after exposure to psychologically traumatic events (eg, threatened death, serious injury, sexual violence) with characteristic symptoms of recurrent flashbacks, nightmares, hyperarousal, avoidance, and numbing. PTSD can also be associated with insomnia, irritability, and difficulty in concentrating, but this patient's history of head trauma and physical symptoms make TBI more likely. Educational objective: Traumatic brain injury (TBI) of any severity can lead to (a few hours to days later) postconcussive syndrome, which is characterized by headache, confusion, amnesia, difficulty in 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 28-Year-Old Previously Healthy Man Comes to the Office with His