CHIEF COMPLAINT: Headache.
SUBJECTIVE: The patient relates that he was hit in the head by a baseball, which was thrown by another player and it hit him on the top of the head while he was picking up another ball, which had rolled over to him from two other players who were having a catch. The player who threw the ball did not realize that he was bending over to pick up the other ball and threw the ball over with the patient bending down.
The patient was struck on the posterior third region on the top of the head. The patient felt notable pain at the time of the injury and fell to his knees holding his head. He did not lose consciousness. He felt dizzy for a period, which lasted approximately two innings, after he sustained the injury. He did not play until he was feeling better.
He relates that he developed a headache a few minutes after he sustained the injury, which occurred between 4 and 4:30 p.m. The patient relates that the headache continued until 7 p.m. that evening at which time it decreased in intensity to a mild ache.
The patient woke up the next morning with headache, which continued through the day. The patient stayed home from school the next day. He did attend a baseball game that evening and played two innings and felt okay while playing.
Two days later, the patient awoke with a headache, which continued after arriving in school, and for this reason, the patient visited the school nurse. The headache continued intermittently into the evening of that day, and the patient went to bed with a headache last evening.
The patient woke up today, three days post injury, with a headache which worsened in school, and the patient again went to the school nurse and was given Tylenol, which helped his headache somewhat. The patient continued, however, with the headache all day today; although, it did become milder after the Tylenol, and presently, the patient states that he has just a mild headache at the current time.
The patient relates that he felt dizzy this morning when he went to the nurse and laid down for approximately one hour and felt less dizzy.
OBJECTIVE:
Vital Signs: Temperature: 98.6, weight 104 pounds, blood pressure 102/62, and pulse 82 per minute.
General Appearance: This young man appears to be a well-nourished, well-developed male.
HEENT: Ears: TMs clear bilaterally. Throat: Clear. Nose: Clear. Eyes: Positive red reflex, disks clear and sharp. EOMI. PERRLA.
Chest: Clear to A and P.
Heart: Regular rhythm, no murmurs.
Abdomen: Soft, no masses, bowel sounds present.
Neurological: No focal deficits. Cranial nerves II through XII grossly intact.
Cerebellar: Finger-to-nose testing intact, rapid alternating movements intact.
Deep Tendon Reflexes: +2 bilaterally.
Romberg Sign: Negative.
Babinski Sign: Negative.
Gait: Normal. The patient can walk on his heels and toes without difficulty.
Sensation: Normal.
ASSESSMENT: Concussion, headache and dizziness, status post blow to the head from a baseball. The patient continues with a mild headache this evening, three days post injury. He has no dizziness at the present time. The fact that he has continued to have headache and intermittent dizziness over the past several days indicates that he has sustained a concussion from his injury. His neurologic exam is normal.
PLAN:
1. Acetaminophen 650 mg q.4 hours.
2. The patient and his father were advised that he should not participate in baseball until all of the symptoms disappear and then he should wait at least two weeks from the time of disappearance of all symptoms before participating in any contact sports and in baseball. We have emphasized the importance of not sustaining another blow to the head, given the patient’s current symptoms, and that he should be symptom-free for at least two weeks before returning to his sport.
3. We advised the patient and his father to return for followup in approximately two weeks.
4. The patient and his father were advised that if at any point his headaches worsened or he developed any focal neurologic signs such as deviation of either one of the eyes or onset of weakness involving any part of his body, that he should get seen immediately at the emergency room for evaluation.
