Author: Sayedmajid Reza Alavi Dehkordi, MD
Co Author #1: Patrick Mularoni,MD
Co Author #2: Patrick Mularoni,MD
Co Author #3: Patrick Mularoni,MD
Editor: Sam Hwu, MD
Patient is a 16-year-old female soccer player, who presented to our clinic for evaluation two days of concussion like symptoms after heading a soccer ball. The patient reported being struck with the ball in the crown of her head in the first half and reported development of headache, difficulty with concentration and fatigue thirty minutes later. She completed the game then started developing increased headache associated with dizziness and nausea without vomiting. On the day of the injury the patient denied ocular complaints including photophobia or vision changes. On the following day, the patient woke up with mild headache. While at school she had worsening headache, difficulty with concentration and she developed right eye itching, redness, photosensitivity and discharge. The patient presented to our clinic two days after the injury with complaints of headache, right eye itching, redness, discharge/tearing and photophobia. At the time she denied nausea/vomiting, neck pain, phono-phobia and vision acuity issues.
On physical examination she was fully alert and oriented, Neurologic exam did not show any motor or sensory deficit. Tandem stance showed truncal correction several times. Romberg was negative. Ocular exam was positive for right sided ptosis with injection of the conjunctiva and some yellow discharge on the lid margin. Patients pupil was reactive but smaller that the left pupil. Case Photo #1 Case Photo #2 Ocular movement revealed undershooting abnormalities with horizontal and vertical saccades. Snellen eye chart testing showed visual acuity 20/20 bilaterally. Retinal exam utilizing a direct Ophthalmoscope did not reveal papilledema bilaterally. The rest of her physical exam including a full neurologic exam was unremarkable.
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