Author: Jessica Tomazic, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Kristopher Paultre, MD

Patient Presentation:
A 17-year-old male high school football player without significant past medical history presented in the outpatient sports medicine clinic for evaluation three days after sustaining his first concussion, during which he was noted to have a brief loss of consciousness for 10-30 seconds. On the day of the exam in the outpatient setting, the patient reported mild neck pain but otherwise had no other complaints. He again reported that he did not recall events from the time of the impact until 30-60 seconds after the injury. Parents reported that he was an A/B student and had no previous learning difficulties.

History:
Three days earlier, he had sustained a hard tackle and was found unresponsive on the field but was roused within seconds of the athletic trainer arriving at his side. The patient was dazed but cleared and able to walk to the sideline. He reported not remembering the 30-60 seconds immediately following the impact but otherwise had a normal sideline exam. Per protocols, he was withheld from play for the remainder of the game. A brief exam was conducted after the game and revealed no acute abnormalities. Two days later during training room, the patient was again examined by the athletic trainer when a lateral gaze defect of the left eye was noted on near point convergence. His parents reported that this had never been noted before.

Physical Exam:
Vitals: signs were normal: supine blood pressure was 108/50 and his pulse was 54.
General: He was well nourished, well developed and in no acute distress.
Neurologic Exam: His pupils were equal, round and reactive to light and accommodation. He had a normal cervical spine exam. He had normal palatal elevation. No pronator drift was appreciated. He had 5/5 strength in all extremities and 2+ and symmetric triceps, biceps, brachioradialis, patellar, and Achilles reflexes. He had normal finger-to-nose testing and heel-to-shin testing. Romberg testing was normal. He had a normal gait, and heel, toe and tandem walk were normal. He had normal smooth pursuits, horizontal and vertical saccades, horizontal and vertical vestibulo-ocular reflex and visual motion sensitivity. Average near point of convergence 1cm from the tip of the nose, with left eye deviation away from the midline that began about 5cm from the nose.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.