Post-Concussive Syndrome: Case Study
Chief Complaint
Post concussive syndrome.
History
Patient is a 55-year-old right-handed white female who does see a neurologist in Florida for multiple issues. She does have a chronic pain issue and has some bradykinesia. Her neurologist down there was concerned about Parkinson 's disease. Also, she was seeing the neurologist for a workup of her episodes of loss of consciousness. She is seeing me today for followup after a concussion. She is from Florida and is expecting to go back in two weeks. The patient does have several episodes of loss of consciousness. She states she usually loses consciousness while she is lying down, but sometimes she will find herself on the floor and not knowing how she got there. On 07/02/2015, she was lying
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Examination
Constitutional
Weight 175 pounds. Height 5 '3". Respirations 12. Pulse 69.
General
She is in no obvious distress.
Mental Status
She is oriented x3, alert and cooperative. Good short-term, long-term and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.
Cranial Nerves
Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvular were midline. Normal auditory acuity. Normal shoulder shrug.
Motor
Was 5/5 throughout with some give-way weakness. She overall has some slowness of movement, but no cogwheel rigidity or bradykinesia.
Sensory
Was decreased in the stocking distribution, right more than left, lower extremity.
Cerebellar
Revealed good finger-to-nose, heel-to-shin and rapid alternating motion.
Gait
Markedly antalgic. Equivocal Romberg.
DTRs
2+ in the upper extremities and knees, trace at the ankles.
Labs/Studies
CAT scan and C-spine are as noted
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Impression
Post concussive syndrome with headache, neck pain, and vertigo. There are not very many medications that I can start her on for her post concussive headaches. I normally would consider amitriptyline, but she is already on two antidepressants, plus she is not going to be here for very long, so I am going to try a more short term approach. She has had a Medrol dose pack in the past without any adverse
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