Adolescent Female with Concussion Symptoms Following Minor Blunt Head Trauma

Case at a Glance

A 16-year-old female presented with headache, dizziness, nausea, and cognitive fog following two direct impacts to the head from a hard object. Without loss of consciousness or other severe red flags, she was clinically diagnosed with a mild traumatic brain injury (concussion) and managed with conservative treatment and education.

Patient's Story

The patient is a 16-year-old female who sustained a head injury during a recreational activity at a pool. She reported being struck forcefully in the head twice by a hard, solid plastic/rubber object. She denied any loss of consciousness at the time of impact. Within hours, she began experiencing a persistent, pounding headache, significant dizziness, and a strong sensation of nausea. The patient's primary concern, beyond the physical symptoms, was a subjective feeling of cognitive impairment, which she described as being unable to 'think straight,' feeling 'foggy,' and a general sense that 'everything feels off.'

Initial Assessment

Upon presentation, the patient was alert and oriented. A physical examination revealed a palpable, tender contusion on her forehead without any overlying laceration. She reported a severe headache and dizziness that was exacerbated by movement. Her chief complaints were consistent with post-concussive syndrome. Vital signs were within normal limits for her age.

The Diagnostic Journey

A neurological assessment was conducted to evaluate for signs of more severe injury. The patient's Glasgow Coma Scale (GCS) was 15. There was no report of loss of consciousness, amnesia surrounding the event, seizures, or vomiting. Examination of cranial nerves, motor function, sensation, and coordination revealed no focal deficits. Based on the history and the classic constellation of symptoms (headache, dizziness, cognitive changes) in the absence of 'red flag' signs such as worsening headache, repeated vomiting, or focal neurological changes, the diagnosis was made on a clinical basis. Imaging studies such as a CT scan of the head were considered but ultimately deferred as per current guidelines for mild traumatic brain injury without high-risk features.

Final Diagnosis

Mild Traumatic Brain Injury (Concussion)

Treatment Plan

The patient was provided with comprehensive education regarding concussion management. The treatment plan included:

1. Relative Rest: A period of both physical and cognitive rest for 24-48 hours was recommended, followed by a gradual, stepwise return to academic and physical activities as symptoms allowed.
2. Symptom Management: Over-the-counter analgesics like acetaminophen were recommended for headache control.
3. Monitoring: The patient and her guardians were given strict instructions on symptoms that would warrant an immediate return to the emergency department, including worsening or severe headache, repeated vomiting, seizures, or any significant change in behavior or consciousness.
4. Hydration and Nutrition: Emphasis was placed on maintaining a regular schedule for meals and ensuring adequate hydration.

Outcome and Follow-up

The patient was scheduled for a follow-up appointment with her primary care physician in 2-3 days to monitor symptom resolution and guide her return-to-learn and return-to-play protocols. The prognosis for a full recovery within several weeks was considered excellent with adherence to the recommended management plan.