Author: Michael Smith, MD, PharmD
Co Author #1: James R. Clugston MD
Co Author #2: Jarrett Schweim ATC/L, CES
Editor: Christopher Lutrzykowski, MD
An 18 year old college freshman football player was noticed by his teammates to be dazed, lethargic, and covering his ears due to sensitivity to artificial noise played during practice. The athletic training staff was alerted and evaluated him immediately in the training room. Because of his imbalance, he required support during transfer to the training room. He also complained of fatigue, headache, dizziness, photophobia, and impaired memory. He stated he felt well hydrated and drank plenty of fluids during practice. He denied any loss of consciousness, significant blow to body or head during practice, fever, visual change, vomiting, diarrhea, or depressed mood. He also denied history of previous concussion. He stated he felt tired and unmotivated and that these complaints actually began earlier in the day prior to practice causing him to miss class. After evaluation, patient took a 90 minute nap in the training room. Patient was re-evaluated upon wakening with no changes but continued to complain of phonophobia and photophobia.
Practice Conditions: Sunny; Temp 87.0 F; Humidity 57.8%; Heat index 94.1 F
Gen: NAD, Alert and oriented x 3
Vitals: Rectal temp 97.8 F, BP 127/74, P 80 RR 18
HEENT: MMM, No LAD, no masses.
CV: RRR; no M/R/G
RESP: Clear to auscultation bilaterally
GI: BS +, soft, NT/ND
Neuro: Mood appropriate; CN 2-12 intact; EOMI; Finger to nose testing normal; DTRâ€™s of biceps, triceps, patella equal and symmetric bilaterally; Romberg test is normal; Heel to toe walking normal; No nystagmus or vertigo with rapid vertical or horizontal gaze. Post Concussion Symptom Scale (PCSS) was 31 compared to 31 at baseline, Standardized Assessment of Concussion (SAC) was 28 compared to 27 at baseline, and Balance Error Scoring System (BESS) was 17 compared to 18 at baseline.
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