HISTORY
10 y/o M football player was referred by PCP for a concussion. Patient was jumping on a bouncy house four days earlier when he fell off and hit his head on the hardwood floor. No LOC. Brought to the ED and diagnosed with a concussion and sent home. Over the next couple of days, had multiple episodes of emesis. Brought back to the ED, CT head showed a right occipital comminuted calvarial fracture with displacement fragment of bone intracranially and with an extra axial hemorrhage that was concerning for a subdural or epidural hematoma. Transferred to Maine Medical Center for a neurosurgical evaluation. Seen by neurosurgery and pediatric rheumatology and discharged home given stable exam. Admits to headache, photophobia, phonophobia, feeling slower, fatigue, drowsiness, difficulty falling asleep, irritability. No history of learning disorders and no previous concussions. Symptom Score 36.
PHYSICAL EXAM
General: NAD
HEENT: TTP right occiput large hematoma. PEERLA,
Neck: No TTP Full ROM. Spurling (-)
Neuro: CN2-12 intact, Sensation/Motor in all extremities intact
Memory short term: word recall (5/5) x 3. long term: intact
Cognitive: Recite months backwards 12/12, Days 7/7, Numbers 3/3, 4/4, 5/5
VOMS: intact, convergence 6cm, finger to nose intact
BESS: two leg no errors, one leg 4 errors, Tandem 2 errors
Psych: mood normal
DIFFERENTIAL DIAGNOSIS
Concussion, TBI, Subdural hematoma, Epidural hematoma, Subarachnoid, Migraine, Basilar Fracture, Occipital Fracture, Seizure Disorder
TEST AND RESULTS
CT head: Right occipital comminuted calvarial fracture with displaced fragment of bone intracranially with extra-axial fluid collection which could be a subdural or epidural hemorrhage component.
FINAL DIAGNOSIS
Concussion, Occipital bone fracture, and Subdural hemorrhage
TREATMENT AND OUTCOME
Return to school with accommodations, avoid bright lights and loud noises, limit screen time, avoid. Per Neurosurgery: Avoid any physical activity for 2-3 months
Follow at 2 weeks: Symptom Score 3. Patient much improved. Exam remarkable for poor balance
Pending Neurosurgery follow up next month. Follow up in clinic office 1 month.