Author: Krishna White, MD
Co Author #1: D. Harrison Youmans, M.D., CAQSM
Senior Editor: Marc Hilgers, MD, PhD, FAMSSM
Editor: Blake Corcoran, MD, CAQSM

Patient Presentation:
A 15-year-old, male, high school football player presented for evaluation following a head injury.

History:
A 15-year-old, male, high school football player presented for evaluation following a head injury that occurred seven days prior. While returning the football, he collided with a teammate, fell to the ground and his helmet bounced off the turf. On the ground, he experienced below the neck full body numbness and tingling for two minutes. He was able to ambulate off the field with assistance, and had a brief episode of uncoordinated movement. He presented to an outside emergency department the following day, and was diagnosed with a concussion. He endorsed moderate headache for four days, but no additional symptoms. Upon further questioning, he divulged that he had a similar event one year prior with loss of consciousness. At that time, he had presented to this institution’s pediatric emergency department where imaging included an abnormal CT scan of the cervical spine, which had been commented on in passing.

Physical Exam:
VITAL SIGNS: Afebrile; vital signs stable.
HEAD: Tender to palpation of temporal regions bilaterally. No other tenderness along the skull.
CERVICAL SPINE/NECK: Full range of motion. 5/5 strength with flexion, extension, and lateral flexion bilaterally. No tenderness to palpation of cervical paraspinal musculature. No bony tenderness over the midline or palpable step-offs.
NEURO: Cranial nerves II through XII grossly intact with no focal neurological deficits. Extraocular eye movements intact. Pupils are equal, round, and reactive to light. Negative saccades testing. No dysdiadochokinesia. No dysmetria. Negative Romberg testing. 2+ peripheral reflexes. 5/5 strength of the upper and lower extremities and digits bilaterally.

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