Exacerbation of Anxiety and Depression Symptoms following Concussion in a High School Softball Athlete.

Abstract

Listen

Translate article

HISTORY: A 16-year-old female softball athlete with a history of pre-pubertal migraines sustained a concussion while doing hill sprints. The injury coincided with a loss of consciousness and anterograde amnesia of 20-30 minutes. She presented to clinic six weeks post-injury with symptoms including headache, academic difficulty, and mood lability. Sleep habits were stable, though quality was reported as poor. Headaches occurred daily with variable intensity, were predominately frontal, and were exacerbated by cognitive effort and bright lights. A previously high-achieving student, she experienced difficulty in her classes, particularly foreign language studies. Patient reported pre-injury mood was poor, but had become more irritable than usual with frequent mood swings. Friends and family commented on her increased irritability. Social history significant for death of mother two years previously. PHYSICAL EXAMINATION: Accommodation insufficiency and difficulty with smooth pursuit on visual examination. Cervical spine tenderness and reproduction of headache with palpation. Otherwise normal neurologic and musculoskeletal exams. DIFFERENTIAL DIAGNOSIS: 1.Post-concussion syndrome with visual dysfunction 2.Depression or anxiety disorder exacerbated by trauma TESTS AND RESULTS: Sensory Organization Test: -Composite score of 68 - abnormal Visual domain. Computerized neurocognitive testing: -Composite score of 48 (baseline 105). -Multiple domains affected. Patient Health Questionnaire-9: -12 of 27 (baseline 7). -21% age-adjusted positive predictive value for depressive disorder. Generalized Anxiety Disorder-7: -12 of 21 (baseline 9). -Increased risk of generalized anxiety disorder. Buffalo College Treadmill Testing: -Maximum heart rate of 160. -No symptom exacerbation. FINAL WORKING DIAGNOSIS: Post-concussion syndrome with predominately neuropsychiatric and visual dysfunction likely contributing to headache and cognitive difficulties. TREATMENT AND OUTCOMES: 1. Referral for full neuropsychological evaluation to assess cognitive function and mood disorder and provide specific recommendations for treatment. 2. Physical Therapy for possible cervicogenic component of headaches. 3. Visual assessment and rehabilitation with neuro-optometrist.