A 21-year-old woman comes to the office for follow-up of a head injury that occurred while playing lacrosse. The patient is a goalie and was hit in the head with the ball yesterday. She had an episode of vomiting at the time but did not lose consciousness. The patient was brought to the emergency department, where she was noted to be confused and unable to recall the events associated with the competition or her injury. Her family reports that she has never had a serious head injury and has no medical concerns. A head CT scan was unremarkable; the patient's neurologic examination was otherwise normal; and she was discharged home with close observation by family members. Today, she has a headache that has responded to naproxen. The patient's neurologic examination is normal, and she remembers 3 of 3 words after five minutes. She would like to know when she can begin to practice sports again. Which of the following is the best response?

Question

A 21-year-old woman comes to the office for follow-up of a head injury that occurred while playing lacrosse.  The patient is a goalie and was hit in the head with the ball yesterday.  She had an episode of vomiting at the time but did not lose consciousness.  The patient was brought to the emergency department, where she was noted to be confused and unable to recall the events associated with the competition or her injury.  Her family reports that she has never had a serious head injury and has no medical concerns.  A head CT scan was unremarkable; the patient's neurologic examination was otherwise normal; and she was discharged home with close observation by family members.  Today, she has a headache that has responded to naproxen.  The patient's neurologic examination is normal, and she remembers 3 of 3 words after five minutes.  She would like to know when she can begin to practice sports again.  Which of the following is the best response?

Quizplus · Accepted Answer

11ec25c8_d161_b0e0_bc81_2144f193510b_MD0003_00 This patient with a recent head injury complicated by vomiting and transient amnesia had a concussion. A concussion is characterized by a transient neurologic disturbance (eg, disorientation, amnesia) that results from mild traumatic brain injury (TBI). Other common signs and symptoms include headache, dizziness, slurred or delayed speech, and incoordination; nausea/vomiting and loss of consciousness may also occur. Initial management includes a thorough neurologic evaluation and often includes a head CT scan, particularly for those who are considered high risk (eg, amnesia for events >30 minutes prior to injury, focal deficits, signs of skull fracture). In the absence of risk factors (eg, anticoagulation, neurologic deterioration) further imaging is usually not required. Premature return to sports play increases the risk of both future concussions and long-term sequelae (eg, chronic traumatic encephalopathy, second impact syndrome); therefore, a graduated return to play protocol has been recommended to reduce this risk. Average-risk adults should rest for ≥24 hours before gradually increasing activity level each 24-hour period they remain asymptomatic, returning to full contact activities no sooner than in 1 week (Choice B). Initial activity should begin with light aerobic exercise, transition to noncontact sports (eg, running), and progress to contact sports (eg, lacrosse); those who develop symptoms should return to the activity level at which they were last asymptomatic for 24 hours prior to activity progression. (Choice C) Patients should undergo a graduated return to play protocol to reduce the risk of recurrent head injury. However, although patients who experience multiple concussions or significant sequalae (eg, posttraumatic epilepsy) should likely permanently avoid contact sports, this patient's solitary concussion does not require permanent discontinuation at this time. (Choices D and E) Although patients with mild TBI are more likely to develop epilepsy, an electroencephalogram is not recommended in asymptomatic patients. Prophylactic treatment does not reduce the risk of developing epilepsy and is not recommended. Educational objective: Concussions are characterized by a transient neurologic disturbance (eg, disorientation, amnesia) that results from mild traumatic brain injury (TBI); headache, dizziness, slurred or delayed speech, and incoordination are also common. After a concussion, average-risk adults should rest for ≥24 hours before gradually increasing activity level each 24-hour period they remain asymptomatic, potentially returning to full contact sports in 1 week.

A 21-Year-Old Woman Comes to the Office for Follow-Up of a Head