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Abstract: An 18-year-old young girl was admitted to the hospital due to a car accident 1 day ago. She presented with a transient disorder of consciousness and complained of unbearable headache with dizziness, nausea and vomiting, and could not recall the circumstances of the car accident. The cranial CT was completed in the emergency room and no significant abnormalities were found. The patient was given symptomatic treatment with anti-dizziness and pain medication, and was advised to rest quietly in bed.
Basic information】Female, 18 years old
Type of disease】Concussion
Hospital】Shandong Provincial Third Hospital
Consultation time】October 2020
Treatment plan】Surgical debridement + oral medication (flunarizine hydrochloride capsule, aminophenol dihydrocodeine tablet, transthyretin capsule)
Treatment period】1 day in the emergency room, 1 week later outpatient follow-up
Treatment effect】The patient’s condition is stable, no special discomfort
I. Initial consultation
The patient, female, 18 years old, accidentally collided with a car while riding an electric bicycle, landed on her head, and developed a transient disorder of consciousness. The cranial CT examination was completed, suggesting a subcutaneous hematoma and no other abnormalities in the brain. Combined with the patient’s medical history, no significant positive signs were seen on neurological examination, and the preliminary diagnosis of concussion was made at the outpatient clinic.
II. Treatment history
The patient did not see any obvious abnormality in the emergency clinic by perfecting blood routine, liver and kidney function, blood glucose, electrocardiogram, head CT, cervical spine CT and chest CT. Combining with the current clinical symptoms, mainly dizziness and headache, the diagnosis of concussion was considered, and the patient was recommended to stay in the emergency clinic for 1 day, while flunarizine hydrochloride capsule, aminophenol dihydrocodeine tablet and transthyretin capsule were given orally to relieve dizziness and headache, and symptomatic treatment was given for head trauma Give surgical debridement and disinfection. The patient was asked to rest quietly in bed. On the second day of checkup, the patient was clear, dizziness and headache were relieved, vital signs were stable, and there was no other special discomfort, so he was discharged. It was recommended to follow up with the outpatient clinic in 1 week.
III. Treatment effect
The patient was examined in the emergency room to rule out cerebral hemorrhage, lung injury and other organ injuries. After symptomatic treatment with medication, the patient fell asleep quietly, and the headache and dizziness were relieved on the second day without any other special discomfort. It was recommended to continue taking the medication, to rest in bed and to avoid mental work. The patient was re-examined 1 week later and said that the dizziness and headache had disappeared, and no significant abnormality was found in the re-examination of the cranial CT examination.
IV. Precautions
We are sincerely happy for the patient’s recovery after treatment. However, patients should be advised to rest for one month after concussion, avoid physical and mental labor, avoid staying up late and ensure sufficient sleep. If the headache becomes unbearable, you should consult a doctor promptly and review the cranial CT to rule out the possibility of chronic cerebral hemorrhage.
V. Personal insight
Concussions are mostly seen after trauma and can generally be fully recovered. In this patient, after standardized treatment, the discomfort was basically relieved, and no other complications occurred. During the recovery period, concussion patients should develop good living habits, mainly rest, quiet bed rest, and reduce physical exercise, and gradually engage in daily work only after the symptoms are completely relieved. Pay attention to traffic safety, observe traffic safety rules, reduce traffic accidents and avoid accidents.