Diagnosis and Management Plan for Concussion in a 17-Year-Old Male

This case study discusses the diagnosis and management plan for a 17-year-old male suffering from concussion after being hit by a football. It includes recommended neurological exams, intravenous migraine therapy, ibuprofen, and non-pharmacology treatments. The patient's medical and social history is also discussed.

Case Study

TABLE OF CONTENT
Diagnoses.....................................................................................................................................3
Management plan for all diagnoses.............................................................................................3
List of diagnosis...........................................................................................................................5
REFERENCES................................................................................................................................7

Diagnoses
In the case of B.H. who is a 17 years old Caucasian male, suffering from headache after he
was hit by football, it can be said that he has concussion or mild traumatic brain injury. Before 1
year and 6 months ago, he had 2 previous hit that jarred his head. Some previous medical and
social history shows that he has memory loss problem and for that he was diagnosed with
ADHD, 3 months ago. he has frequent and painful headache. He had appendix removal at the
age of 12. Other than this, he was fit and healthy and not suffering from any critical disease.
On the basis of his history, some diagnosis may suggest as a primary care provider. Some
diagnosis that may help him out include:
Neurological exams:
Neurological function and reflexes
Verbal, written as well as computerized test
Memory and concentration
Intravenous migraine therapy
Medicines
Ibuprofen
Non-pharmacology treatments
Encouraging eating
Aseptic technique
Management plan for all diagnoses
On the basis of some subjective and objective data, it can be said that patient is suffering
from concussion. The most common symptom of concussion is: headache. After he was hit, he is
suffering from headache and before that also, he had frequent painful headache. So, on this basis,
some diagnosis has been recommended to B.H. For improving health with these diagnosis, there
is requirement of management plan that include:

Diagnosis or interventions Effectiveness Time
Neurological function and
reflexes
As it is known that patient had
psychiatric illness because he
was facing problems in
concentrating on his studies
and forget football plays many
of the time. So, for this
purpose, neurological test is
being recommended
(Previnaire, 2018). It will help
out in assessing his sensory
skills, balance, vision,
coordination and hearing and
speech skills.
Within 10-12 days
Intravenous metoclopramide It is a medicine that can be
given to patients who are
suffering from migraine or
headache. It relieves their
painful headache. So, as per
the case of B.H. it can be said
that it will help him out from
headache.
Within 3-4 months
Ibuprofen It is found that B.H is having
400 mg every 6-8 hours (3-
4tablets). It helps him out in
relieving headache. But he
takes 3-4 tablets that might
affect him in the future. As per
his criteria and age, it can be
Around 3-4 months

suggested that he should take
only 2 tablets (Petrelli and
et.al., 2017).
Encouraging healthy eating It is found that in this situation
and concussion, patients do
not eat too much or in a proper
manner. But having nutritional
values of food is essential so,
client will be encouraged for
having healthy food. It can
cure his headache and
vomiting problems.
Long term
Aseptic technique It is a collection of medical
practices that help patients
from germs. It is being used
after appendix removal
surgery. It can protect patient
from bleeding and urine
infection.
10-15 days
List of diagnosis
Attention deficit hyperactivity and impulsiveness
Ibuprofen: 400 mg every 12 hours
Intravenous metoclopramide

Neurological function and reflexes
Encouraging eating

REFERENCES
Books and Journals
Petrelli, T. and et.al., 2017. The use of ibuprofen and acetaminophen for acute headache in the
postconcussive youth: a pilot study. Paediatrics & child health, 22(1), pp.2-6.
Previnaire, J.G., 2018. The importance of the bulbocavernosus reflex. Spinal cord series and
cases, 4(1), pp.1-2.