Author: Ty Jones, MD
Co Author #1: Wade Gaal, MD
Co Author #2: William Rosenberg, MD

Patient Presentation:
An 18 year old female NCAA Division I basketball player with a past medical history significant for 7 prior concussions – the last 2 years ago – was elbowed in the right cheek during a game. The team athletic trainer observed the incident and pulled her from play for evaluation. She was returned to the game after denying any concussive symptoms and completing the SCAT3 courtside without difficulty.
Three days later, she presented to the athletic training room clinic with complaints of frontotemporal headache, nausea, dizziness, photosensitivity, and phonosensitivity. She also endorsed feeling slowed down, irritability, and drowsiness. On exam, she was tender to palpation over the right inferior orbit and had worsening headache and dizziness with vestibular testing. ImPACT testing demonstrated a total symptom score of 15 and a deficit in reaction time (scored at the 25th percentile, down from her baseline at the 92nd percentile) and a decrease in her cognitive efficiency index from 0.37 to 0.27. She was sent for CT of the right orbit which showed a subtle right maxillary sinus fracture at the anterior wall without displacement, for which she was cleared by ENT over the course of a week. Her concussion symptoms resolved by post-injury day 8. Once asymptomatic, ImPACT was repeated and demonstrated a return to baseline. She was returned to sport per a graduated return-to-play protocol without complications and played the full season.
The athlete returned to the training room clinic 8 months later for her pre-season physical exam. She complained of 2 months of constant throbbing bilateral frontotemporal headaches – worse with exercise – and difficulty concentrating in class. Her headaches would occasionally wake her from sleep and were usually relieved by Advil. She denied nausea, vomiting, vision changes, weakness, or new trauma.

History:
PMH: 8 concussions and right orbital fracture, per above.
PSH: None.
FH: No significant hx.
SH: Negative for tobacco, alcohol, or intravenous drug use.
Meds: Advil PRN.
Allergies: NKDA.

Physical Exam:
VITALS: BP 99/64 HR 53 RR 12 Temp 98.8
GENERAL: Healthy-appearing athletic female in no acute distress.
HEENT: EOMI, PERRLA. Fundoscopic exam unremarkable. TMs clear and shiny. No facial tenderness to palpation. Visual convergence at 4 cm. Reproduction of headaches with alternating vertical gaze and fixed gaze testing with head rotation.
NECK: Supple. Full painless AROM. No nuchal tenderness.
HEART: Regular rate and rhythm.
CHEST: Lung fields clear to auscultation bilaterally.
NEUROLOGIC: Awake, alert, and oriented. CN II-XII intact. Normal gait and station. Negative Romberg. Normal single leg stance, tandem stance, heel-toe walk, and finger-to-nose. Normal strength in all 4 extremities. 2+ deep tendon reflexes at knee, ankle, biceps, and triceps. Sensation grossly intact in bilaterally upper and lower extremities. Fluent speech.
PSYCH: Appropriate mood and affect.

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