Author: April Barnum, DO
Co Author #1: F. Allen Richburg, MD, MS, FAAFP; San Diego Sports Medicine and Family Health Center, Sorrento Valley Office, 4010 Sorrento Valley Boulevard, Suite 300, San Diego, CA 92121; San Diego State University Athletics Medicine, 5500 Campanile Drive, San Diego, CA 92182.
Senior Editor: Mandeep Ghuman, MD, FAMSSM
Editor: Bernadette Pendergraph, MD

Patient Presentation:
An 18 year old college freshman presents for a preparticipation exam to play football at the Division I level.

History:
His past medical history included 3 diagnosed concussions sustained in high school (one with a loss of consciousness), episodic tension headaches, left ventricular hypertrophy, and hypertension. His hypertension was managed through lifestyle modifications. He has been medically cleared by a cardiologist for full participation in practice and competition for college football.

The athlete continued high school football and high school wrestling despite sustaining 3 concussions. His first concussion, during which he suffered a loss of consciousness, occurred during wrestling in early 2017. His second concussion occurred during football in October 2018. He experienced a headache, which lasted for a few minutes, then resolved. He continued to play football that day. A few games later, he was observed by his teammates to be disoriented on the field. He was removed from play and enrolled in the Concussion Clinic. His symptoms ultimately improved and he was able to complete the rest of the football season. He sustained his third concussion in December 2018 while playing football, which was without a loss of consciousness and resulted in a headache. An MRI of the brain without contrast was performed in April 2019 due to persistent headaches.

The patient has had episodic tension headaches for the past 2 years. The headaches occurred in the bilateral temporo-parieto-occipital region. His headaches occurred 3 times per week but he denied any headaches with exercise. The headaches were 10-40 minutes in duration. He rated the pain as 4 to 6 out of 10 on average. His headaches were aggravated by stress. He infrequently took ibuprofen or acetaminophen as needed for headaches, with some symptomatic relief.

His family history was non-contributory.

His review of systems was completely normal. At evaluation, he did not have any headaches or other neurologic symptoms.

Physical Exam:
Neurologic Exam
Mental Status: He was awake, alert, and oriented to person, place and time. His registration, attention span, recent and remote memory were intact. His naming and repetition were normal. His judgment and insight were fair. He was able to process 3-step commands, read and write, and had no tangential thought processes.
CN II-XII: No cranial nerve deficits.
Motor: He had normal muscle mass, tone, and strength in all major groups. He had no pronator drift.
Sensory: Sensation intact to pinprick, light touch, and double sensory stimulation.
Reflexes: He had 2+ symmetric bilateral upper and lower extremity reflexes.
Coordination: His rapid alternating movements and finger-to-nose testing was normal. He had no tremor or dysdiadochokinesia. His heel-to-shin testing was normal.
Gait: His gait was normal. His Romberg test was negative. He was able to do toe walk and heel walk.
In summary, the neurologic exam was completely normal.

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