Post-Concussive Syndrome: Case Study

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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…show more content…
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…show more content…
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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