Author: Aubrey Armento, MD
Editor: James Robinson, MD
A thirteen year-old male presented to the Sports Medicine clinic for evaluation of a concussion.
He sustained a head injury during a football game when he was tackled and hit the back of his head onto the ground. He was wearing a helmet at the time. There was no witnessed loss of consciousness. He felt dizzy and confused and quickly developed a headache following the injury. He was placed in a C-collar due to neck pain. Upon evaluation in the emergency department immediately after the injury, cervical spine radiographs were obtained and reportedly normal, so the C-collar was removed. No head imaging was performed. He was diagnosed with a concussion and discharged home. In the emergency department, his parents noted new onset drooping of his left upper eyelid. Upon presentation to our clinic, he had continued headache, photophobia, and left eyelid drooping.
The patient was awake, alert, and oriented with normal cognition and regular speech. Cranial nerves II through XII were intact other than notable left-sided ptosis. He was unable to fully open the left eye. Extraocular movements were intact. Motor and sensory testing was normal in all four extremities. Tandem gait was intact. Romberg was negative, but he demonstrated a fine bilateral hand tremor. Rapid hand alternating movements were normal. He was tremulous with finger-to-nose testing, worse on the left. There was symptom provocation with horizontal and vertical saccades in 10 seconds. Convergence and accommodation could not be adequately tested due to the left-sided ptosis.
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