Author: Colton Wood, MD
Co Author #1: Colton Wood, MD
Co Author #2: Mario Ciocca, MD
Senior Editor: Carolyn Landsberg, MD
Editor: Adam Lewno, DO

Patient Presentation:
A 21-year-old NCAA Division 1 defensive lineman who was recovering from a recent flu-like illness reported fatigue and vague head discomfort after he hit the back of his head on an opponent's knee during a fourth quarter tackle.

History:
A 21-year-old NCAA Division 1 defensive lineman reported fatigue and vague head discomfort after he had hit the back of his head on an opponent's knee during a fourth quarter tackle. The patient was evaluated immediately within the sideline medical tent and noted to have a normal neurologic exam, vestibular/ocular motor screening, and modified BESS testing without any provocation of symptoms. Of note, the athlete was five days post acute febrile viral illness treated with Tamiflu, naproxen, rest, and hydration. The patient felt more fatigued compared to what he had experienced throughout the week leading up to the game. He returned to game play without provocation of symptoms during the remaining few minutes of game play. However, on the way home from the game, he developed an immediate headache and photophobia after passing by police lights. The following day he reported improvement in headache and fatigue. He was allowed to attend team meetings but was withheld from physical activity for one day. Two days after the game, during a noncontact practice, he noticed a painless, "filmy" haziness, and black spots within his right field of vision. He was evaluated on the sideline and had normal neurologic and ocular exams. He was encouraged to return home, remove monthly contacts, and monitor his symptoms. The following day the patient reported continued constant black spots within his right visual field prompting an evaluation with an optometrist.

Physical Exam:
At the time of optometrist evaluation
HEENT:
Normocephalic, atraumatic, pupils equal round and reactive to light, painless and intact extra ocular motion, normal vestibular ocular motion. Normal conjunctiva. Normal periocular and cervical lymph nodes. No afferent pupillary defect.
OPHTHALMOLOGIC::
Visual acuity: Right eye: 20/50. Left eye: 20/20.
Visual field: Inferior paracentral defect in right eye. No left eye defects.
Cup-to-Disc ratio: 0.3.
Tonometry normal.
Fundoscopic exam normal.
Slit-Lamp exam: Normal cornea, conjunctivae, anterior/posterior chambers, iris, lens, vitreous body, macula, optic nerve, and retina.
NEUROLOGIC:
Alert and oriented to person, place, and time.
Short term recall was 3/3
Cranial nerves II through XII were grossly intact
Strength was 5/5 bilaterally with normal tone throughout
Sensation intact to light touch throughout bilateral lower and upper extremities.
Reflexes were 2+ and symmetric in the bilateral lower extremities.
Finger-to-Nose and rapid alternating movements intact without any ataxia.
Normal stance and gait.
Negative Romberg and no pronator drift
Normal single leg squat.
Modified BESS on turf without errors.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.