Author: Aliza Williams, DO
Co Author #1: Megan Hanna, MD
Co Author #2: Elizabeth Harpster, MD
Senior Editor: Justin Mark Young, MD, FAMSSM
Editor: Elizabeth Albright, DO

Patient Presentation:
A 20-year-old female college cheerleader with a history of recurrent concussions presented to the student health center reporting short-term memory loss for 1-2 weeks following spring break. She endorsed increased stressors at school and more frequent cheer practices. She denied any new trauma. Her symptoms were exacerbated with physical activity and included disorientation, disassociation, and weakness resulting in missed classes. Her neurologic exam was normal at the clinic and she was discharged home with suspected viral illness vs anxiety with recommendation for close follow up. That night, she was brought to the emergency department by her sister due to worsening short term memory recall, new intermittent paresthesia of her extremities, and difficulty initiating speech. She was admitted for further workup.

History:
Patient denied new medications or high risk behaviors including new sexual partners, unprotected intercourse, excessive caffeine use, recreational drug use, or excessive alcohol use outside of spring break. She denied any personal or family history of seizure disorders or thyroid dysfunction. Her sister had previously been diagnosed with Type 1 Diabetes Mellitus.

Physical Exam:
Vitals: Afebrile and normotensive during hospitalization.
General: Well-appearing.
HEENT: Normocephalic, atraumatic head. Extraocular movements were intact. Pupils were equal and reactive bilaterally.
Cardiac: Unremarkable
Pulmonary: Lungs were clear to auscultation.
Musculoskeletal: Upper and lower extremities had full range of motion and normal strength. She was able to ambulate without difficulty.
Neurologic: She was alert but disoriented. Cranial nerves II through XII were intact. There was no clonus. Finger-to-nose testing was intact. She had equal sensation to light touch. She stated the incorrect year and was unable to state the month. She had decreased concentration with limited attention less than 60 seconds. She was able to repeat phrases without any aphasia or dysarthria.

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