A 42-year-old, previously healthy woman comes to the office 3 weeks after an emergency department visit due to a motor vehicle accident. She was a restrained driver in a high-impact accident during which she briefly lost consciousness after hitting her head. Evaluation in the emergency department, including CT scan of the head and cervical spine, was normal. Since the accident, the patient has had intermittent headaches, dizziness, anxiety, and insomnia. She is not able to remain focused on anything and has a sensation of "mental clouding". She has had no nightmares or flashbacks of the accident.
Her temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, and pulse is 78/min. Cardiopulmonary examination is normal. Muscle power is symmetric, sensations are intact, and deep tendon reflexes are normal. Her mood and memory are normal.
MRI of the head is normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 42-year-old, previously healthy woman comes to the office 3 weeks after an emergency department visit due to a motor vehicle accident.  She was a restrained driver in a high-impact accident during which she briefly lost consciousness after hitting her head.  Evaluation in the emergency department, including CT scan of the head and cervical spine, was normal.  Since the accident, the patient has had intermittent headaches, dizziness, anxiety, and insomnia.  She is not able to remain focused on anything and has a sensation of "mental clouding".  She has had no nightmares or flashbacks of the accident.
Her temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, and pulse is 78/min.  Cardiopulmonary examination is normal.  Muscle power is symmetric, sensations are intact, and deep tendon reflexes are normal.  Her mood and memory are normal.
MRI of the head is normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient is presenting with post-concussive syndrome following mild traumatic brain injury (TBI). TBI symptoms will most likely improve (70%-80% of cases) within 3 months with symptom-targeted pharmacologic and nonpharmacologic strategies. TBI of any severity can lead (a few hours or days later) to post-concussive syndrome, which is clinically described by the following constellation of symptoms: Headache, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. Typically, these symptoms resolve within a few weeks to months following TBI; however, some patients can have symptoms that persist for 6 months or more. (Choice A) For most patients with post-concussive syndrome, neuropsychological testing is not necessary (routine bedside/office mental status examination that includes frontal lobe tasks is usually adequate). However, patients with a history of moderate to severe TBI or significant cognitive symptoms, especially if not improving within the expected time frame, should be considered for comprehensive neuropsychological testing to help with long-term management and rehabilitation. (Choice B) Prolonged in-patient electroencephalogram (EEG) monitoring can be used to rule out non-convulsive/subclinical status epilepticus. Appropriate use includes patients with moderate to severe TBI associated with brain edema and/or hemorrhage who are in a medically induced coma or those having fluctuating levels of consciousness or frequent intermittent seizures without return to normal mental status. Short-term, routine, and/or prolonged ambulatory EEG monitoring should be considered in patients who had a posttraumatic seizure to assess their seizure recurrence risk and need for antiepileptic therapy. (Choice D) Comorbid psychiatric conditions such as major depression and posttraumatic stress disorder may develop with TBI and can be treated with antidepressants and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs) (eg, sertraline) are commonly used as first-line therapy. Given that this patient has no persistent mood symptoms, an SSRI is unnecessary at this time. (Choice E) Thyroid dysfunction (hypo- or hyperthyroidism) can be associated with symptoms similar to those seen with post-concussive syndrome; however, the proximity of this patient's head trauma to her symptoms makes post-concussive syndrome a more likely diagnosis. Educational objective: Traumatic brain injury of any severity can lead (a few hours or days later) to post-concussive syndrome, which is clinically described by the following constellation of symptoms: Headache, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. The majority of patients usually improve within weeks to months with symptomatic treatment. __________ References: The current status of postconcussion syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21346569) Management of concussion and post-concussion syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/16901381)

A 42-Year-Old, Previously Healthy Woman Comes to the Office 3