A Sailboat Accident Revealed Three Diagnoses!
A 16-year-old girl was brought to the sports clinic with complaints of headache, dizziness, imbalance, fatigue, irritability, and difficulties with sleep and concentration. Her symptoms started after she suffered trauma during a sailboat race.
The patient was struck by another team’s boom during a boat race 11 days back. Her team’s boat tipped on collision. According to her mates, she had dazed and was confused right after, but she was brought back to the boat, and they continued the sail.
During the sail, the boat tipped over again due to the weather conditions. During this incident, the patient had lost consciousness and was brought to the shore and attended by the emergency medical services personnel. She was awake and confused at that time.
She was taken to the emergency department of a nearby hospital.
In the emergency department, the patient was confused, dizzy, unsteady, and had a headache. On examination, there were no remarkable findings. Neurological examination and the radiographs of the cervical spine were normal too.
The patient was discharged with an advice to rest but to return if symptomatic.
During these 11 days, i.e. after the discharge and till her current presentation, she had several episodes of sharp frontotemporal headaches, dizziness, balance problems, fatigue, lack of concentration, and sleep disturbances. Her headaches were aggravated by reading. Overall she felt agitated and impatient.
The past history revealed multiple sports-related injuries.
On examination, the patient was alert and responsive. The mental status examination was normal. The positive findings on examination included photophobia and pain with an upward gaze. The near point of convergence was 15 cm. Both nodding and side-to-side movements of the head caused dizziness. Romberg test was performed during which she mildly swayed while standing with her feet together and eyes closed. Mild difficulties with double-leg, single-leg, and tandem stance on a hard surface were observed.
The rest of the examination was normal.
A working diagnosis of concussion was made.
Two days later, the patient’s father called to report a forgotten history: the patient had been having nosebleeds since the sailboat accident. The bleeding from the right nostril continued 15 minutes every morning, and thin, clear fluid had drained from her nose on the day after she had been seen in the clinic. She told that the bleeding abated each time with pinching pressure to the nose. Dried blood was noticed in the right nostril on physical examination.
All of the serological investigations, including the coagulation profile, were normal. Dual-energy CT angiography of the head was unremarkable. No basilar fracture was seen.
The patient was treated as a case of concussion.
- She was advised against complete bed rest and was instead advised to start daily activities of life, as tolerated.
- Avoid triggers that aggravate her headache: avoid stress and avoid fasting.
- Get proper sleep (she was educated about sleep hygiene)
- Maintain adequate hydration.
- Acetaminophen PRN for persistent headaches no more than two or three times per week.
For dizziness and imbalance symptoms, she was referred to a physical therapist, where she was diagnosed with benign paroxysmal positional vertigo (BPPV).
Epley maneuver was performed, and treatments were provided for vestibular and ocular impairment.
Despite the resolution of BPPV symptoms, her cognitive struggle of reading and test-taking persisted.
The neuropsychological assessment diagnosed her with attention-deficit hyperactivity disorder, which was not the result of the recent concussion. She had symptoms since childhood, and her brother was also a diagnosed case of ADHD.
The patient and the family were counseled, and the patient was provided with relevant care for ADHD.
Source: Iaccarino, Mary A., Zafonte, Ross D., Roy, Emily D., Wojtowicz, Magdalena, Case 27-2019: A 16-Year-Old Girl with Head Trauma during a Sailboat Race; New England Journal of Medicine August 29, 2019, 381(9):863
