August Week 3: Concussion
You see a 16 year old football player who sustained a hard hit to his head during a football game Friday evening. He was evaluated by the coach, who pulled him out of the game because of momentary loss of consciousness and continued headache throughout the game. He has not been to the ER or otherwise seen a physician. It is Monday morning and he has been sent to you, his pediatrician, for clearance to return to play. He notes he has noticed a mild headache when he wakes in the morning and when he does his homework, similar to the one he had on Friday evening after his hit, but after he drinks two glasses of water he usually feels fine. His physical exam is benign, including no bleeding behind his tympanic membranes, no periorbital bruising, supple neck, completely normal neurological testing including normal gait. He is oriented, answers your questions easily, and recalls the events of Friday night. He is eager to return to the game because his team is doing very well this season.
1. How do you define a concussion?
2. When should an athlete with concussion seek medical attention? (i.e. go to the ED)
a. Repeated vomiting
b. Severe/progressive headache
d. Unsteady gait
e. Slurred speech
f. Weakness/numbness in extremities
g. Chance of skull fracture
h. Altered mental status
i. All of the above
3. If you suspect a skull fracture, what imaging modality should you use?
a. 4-view skull films
b. CT without contrast
c. CT with contrast
d. MRI without contrast
e. MRI with contrast
4. What can you tell your patient about symptomatic management of headache?
a. Go ahead and use ibuprofen or acetaminophen, but be sure to follow instructions
b. Avoid ibuprofen
c. Avoid activities that cause symptoms
d. A and C
e. B and C
5. When can he return to football practice and football games?
a. When symptom free with just occasional use of Tylenol
b. When symptom free off medication
c. When symptom free aside from depression
6. Your patient’s parents ask you if you can write a note to excuse your patient from his calculus final tomorrow. How do you respond?
a. He should be ready since he’s been acing all his quizzes and studying hard, so there’s no need to delay the final
b. You can write a note but if the teacher rejects it there’s nothing you can do since there’s no evidence to delay test-taking
c. You recommend delaying testing until he is recovered, because there is evidence of poor test performance in symptomatic concussed patients
7. What recommendations should you make about exercise in your patient?
a. Continue with training, but avoid games
b. Continue with only light training until headaches completely resolve
c. Continue with training with no chance of impact, such as weight lifting, until headaches resolve, because of the chance of second-impact syndrome
d. Discontinue all training until headaches resolve, because this will speed recovery
Case by Dr. Ha-young Choi