Q: concussion

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Q: concussion

Author

8 Posts

sing
Forum Guru

Topics: 153
Posts: 370

10/14/06 - 07:43 AM

19yo m is brought to er because of a bicycle accident. he was riding with a group of friends who noted that the patient's bike hit a rock, the bike tumbled, and the patient's head hit the pavement. unconsciousness lasted about 30s. it is now approximately 1h after the accident. at this time the patient is alert, though he was thrown up once and complains the difficulty in concentration and blurred vision. furthermore, he is complaining of a severe frontal headache. p/e is notable for the absence of blood at the tympanic membranes and the mastoid processes and a completely nonfocal neurologic exam. skull x-rays and mri are normal. the most appropriate course of action at this point is to
a. obtain a neurosurgical consultation
b. admit the patient to the hospital for observation
c. administer phenytoin and admit the patient to the hospital for observation
d. perform an eeg
e. discharge the patient home in the care of his friends

A&Y thanks.

royalgeorge
Forum Elite

Topics: 10
Posts: 266

10/15/06 - 09:07 AM

The answer must be admit and observe for 24 hours.

But few things in this question are odd-- MRi has no role in imaging initially, ct was better.
IF friends were ready to wake him up periodically for next 24 hours he could have been sent with them.
So overall poor question.

sing
Forum Guru

Topics: 153
Posts: 370

10/16/06 - 11:35 PM

i chose "admit and observe" as well. but the answer was "discharge". maybe wrong answer again. thanks royalgeorge for answering my mcqs.

webjeee
Forum Guru

Topics: 99
Posts: 350

01/01/07 - 08:30 AM

E. already said in the care of his friends

drvic
Forum Elite

Topics: 10
Posts: 181

01/02/07 - 12:38 AM

the five major red flags in this case are: unconsciousness for 30 sec, 1 episode of vomiting within an hour, difficulty concentrating, frontal headaches and blurred vision.

He did present with signs of a minor closed head injury to begin with but what has happened since then is the development of new symptoms. most patients with minor closed head injury are re-evaluated at 2 hours (some even say upto 4 hours) post head injury. if they have vomiting, signs of raised ICT, drop in GCS etc, they get a CT scan and then decision to admit or not is made on the CT findings. so in that respect, the question is INCOMPLETE.

in the real world, i've seen far too many patients get admitted even when they have one or two of those red flags enumerated above. but for this case, the findings are really ominous and shouting for a CT scan.

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srf
Forum Guru
avatar

Topics: 73
Posts: 405

01/12/07 - 06:32 AM

MRI detects soft tissue changes in a excellent way. as MRI is normal patient can be disharged. had initial investigation were CT ,admission would have a right step.if original q is not wrong than this could be a possible explanation

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drvic
Forum Elite

Topics: 10
Posts: 181

01/13/07 - 03:02 PM

MRI is truly good for soft tissue changes but for initial radioimaging of closed head injury CT is the imaging modality of choice. all clinical guidelines say that CT should be the initial imaging for head injury patients. nobody is going to spend 45 minutes to acquire an MRI for an unstable patient with head injury to decide whether patient is going to need the services of a neurosurgeon or not when CT can give you that answer in 5 minutes.

In case you are interested in a more convincing reference, please read the latest issue of NEJM (Jan 11 2007) - Clinical Practice Section - title of the article is "Concussion". here's the link

http://content.nejm.org/cgi/content/full/356/2/16...

it clearly says that CT without contrast should be done...MRI is not necessary.

i certainly hope we don't get such misleading questions in the real exam, especially when step 3 is supposed to be a management based exam

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AAAAA
Forum Fanatic

Topics: 156
Posts: 1,991

01/29/07 - 01:03 PM

sing wrote:
19yo m is brought to er because of a bicycle accident. he was riding with a group of friends who noted that the patient's bike hit a rock, the bike tumbled, and the patient's head hit the pavement. unconsciousness lasted about 30s. it is now approximately 1h after the accident. at this time the patient is alert, though he was thrown up once and complains the difficulty in concentration and blurred vision. furthermore, he is complaining of a severe frontal headache. p/e is notable for the absence of blood at the tympanic membranes and the mastoid processes and a completely nonfocal neurologic exam. skull x-rays and mri are normal. the most appropriate course of action at this point is to
a. obtain a neurosurgical consultation
b. admit the patient to the hospital for observation
c. administer phenytoin and admit the patient to the hospital for observation
d. perform an eeg
e. discharge the patient home in the care of his friends

e

A&Y thanks.

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