Author: Andree Jones, DO
Co Author #1: Brent S.E. Rich, MD, ATC
Editor: Young Yoon, MD
A fourteen year old male football player presents to the office two days following a flexion and extension injury to his neck and head impact following a tackle.
He did not lose consciousness. He did have significant retrograde and anterograde memory loss. He complained of a constant, non-radiating headache, as well as, pain in his neck with movement. He had normal mental status following the injury. He complained of nausea but denied numbness or weakness. He also denied chest, abdominal or extremity pain. He improved with rest until day twenty-five following the injury when his symptoms got spontaneously worse, including significant vision changes. These were so severe, he was only able to see some shapes.
His medical history is significant only for being born via emergency c-section due to triple nuchal cord. He had no prior documented concussions. He did fall backwards off a five foot fence the summer prior to this injury, but did not have concussive symptoms at that time.
He had stable vital signs and was alert and oriented despite having sluggish movements. His head was normo-cephalic and his pupils were reactive with the left pupil being larger than the right by one millimeter. He had posterior neck tenderness but no step-offs or deformities. His cranial nerves two through twelve were intact and nonfocal. His cerebellar testing of finger-nose and rapid alternating movements were normal. His strength was 5/5 in all myotomes and reflexes were 2/4 equal bilaterally in his upper extremities and lower extremities.
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