head injury delayed care

fedor

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    35yo male patient presents directly to neurologist 2 weeks after a head injury (assault). hx of hypertension and previous head injury (mild). Didn't seek care at the time of the assault because he states "was drunk and didn't even have a headache." patient unsure whether or not he lost consciousness at the time of the assault but says most likely he didn't.

    Complaints include vomiting for one day after trauma, nausea for 2 weeks after trauma, stiff neck for a few days after trauma, tingling in all extremities for nearly 2 weeks, drowsiness, difficulty concentrating.

    Assuming neurologic exam is unremarkable, what would you suggest is the next step? CT? MRI? Or would you send the patient home w/ post concussion syndrome?

    What is the most likely dx based on the history w/o assistance from imaging?
     

    TruTrooper

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      fedor said:
      35yo male patient presents directly to neurologist 2 weeks after a head injury (assault). hx of hypertension and previous head injury (mild). Didn't seek care at the time of the assault because he states "was drunk and didn't even have a headache." patient unsure whether or not he lost consciousness at the time of the assault but says most likely he didn't.

      Complaints include vomiting for one day after trauma, nausea for 2 weeks after trauma, stiff neck for a few days after trauma, tingling in all extremities for nearly 2 weeks, drowsiness, difficulty concentrating.

      Assuming neurologic exam is unremarkable, what would you suggest is the next step? CT? MRI? Or would you send the patient home w/ post concussion syndrome?

      What is the most likely dx based on the history w/o assistance from imaging?


      Well, since the Sxs appeared after the "mild" head injury, I would suspect some sort of intracranial bleed (subdural hematoma), especially since he has a hx of, trauma, HTN and gets "drunk". I wouldn't send this guy home without a CT with those Sxs and Hx. I would do the CT first and go from there.

      If I am wrong, I would actually do what is right. :D
       

      kapMD/PhD

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        I am not convinced that it could possibly be a current subdural hematoma, considering that he is apparently alive and this is 2 weeks after the initial trauma and symptoms starting. The classic subdural hematoma is the "talk and die" in which there is a relatively short lucid period followed by death. It is definately possible that there is some sort of intracranial bruising. I wish that i could see the picture, but it's too small - or i'm too old see it that well.
        Order #1 = CT, if nothing notable = MRI
        Other questions needing answers - was this an open injury - in other words is there a chance of an incubating meningitis? if this is possible --> spinal tap and start antibiotics.
        Let me know what happened.
         
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        neurologist

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          kapMD/PhD said:
          I am not convinced that it could possibly be a current subdural hematoma, considering that he is apparently alive and this is 2 weeks after the initial trauma and symptoms starting. The classic subdural hematoma is the "talk and die" in which there is a relatively short lucid period followed by death. It is definately possible that there is some sort of intracranial bruising. I wish that i could see the picture, but it's too small - or i'm too old see it that well.
          Order #1 = CT, if nothing notable = MRI
          Other questions needing answers - was this an open injury - in other words is there a chance of an incubating meningitis? if this is possible --> spinal tap and start antibiotics.
          Let me know what happened.


          The classic EPIDURAL hemorrhage is the "talk and die" scenario (and I've seen it, literally). The scenario presented by the original poster could be consistent with a SUBdural, which can progress slowly over a period of days or even weeks. The meningitis issue is a good question to raise; we are not told about open injury, but even closed head trauma involving fracture of the frontal sinuses can cause meningitis by direct extension of bacteria into the cranial cavity. If this were true bacterial meningitis, he'd probably be sicker than we are led to believe here. We're also not told what his neuro exam is . . . nonfocal, hemiparetic, or what. With this history and a normal exam, MOST LIKELY this is a post-concussion syndrome, but I'd still shoot a CT to check for bleed and fractures, if it wasn't done at the time of injury. You can add contrast if you're thinking about infection/abcess. I'd also get a C-spine x-ray. Consider MRI of the brain if no improvement with conservative treatment over a couple more weeks.
           

          TruTrooper

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            kapMD/PhD said:
            I am not convinced that it could possibly be a current subdural hematoma, considering that he is apparently alive and this is 2 weeks after the initial trauma and symptoms starting.

            Yes, but subdural hematomas can present anywhere from immediately after head trauma or up to several weeks afterwards. It seems 2 weeks is the time for this patient. Since subdural hematomas are the result of tearing of bridging veins which is a low pressure sytem compared to arteries, the effects do not necessarily present as quickly as epidural hematomas.

            As Neurologist pointed out, epidural hematomas has the lucid interval and involves the miningeal arteries (high pressure sytem) and the effects usually manisfest within minutes to hours.

            I would say he has subdural until the CT says "no way." And by "he" I mean "Neurologist." Just kidding :laugh:
             

            kapMD/PhD

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              neurologist said:
              The classic EPIDURAL hemorrhage is the "talk and die" scenario (and I've seen it, literally). The scenario presented by the original poster could be consistent with a SUBdural, which can progress slowly over a period of days or even weeks. The meningitis issue is a good question to raise; we are not told about open injury, but even closed head trauma involving fracture of the frontal sinuses can cause meningitis by direct extension of bacteria into the cranial cavity. If this were true bacterial meningitis, he'd probably be sicker than we are led to believe here. We're also not told what his neuro exam is . . . nonfocal, hemiparetic, or what. With this history and a normal exam, MOST LIKELY this is a post-concussion syndrome, but I'd still shoot a CT to check for bleed and fractures, if it wasn't done at the time of injury. You can add contrast if you're thinking about infection/abcess. I'd also get a C-spine x-ray. Consider MRI of the brain if no improvement with conservative treatment over a couple more weeks.
              RIGHT - good call thanks - one day i'll remember to keep those 2 straight
               
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