Differential Diagnosis for a 17-year-old Patient with Headache, Nausea, and Ringing in the Ears after a Fall

Single Most Likely Diagnosis

• Concussion: Given the patient's recent history of falling down stairs, a concussion is the most likely diagnosis. The symptoms of headache, nausea, and possibly the ringing in the ears (which could be indicative of tinnitus, a common symptom following head injury) align with post-concussive syndrome.

Other Likely Diagnoses

• Post-Traumatic Migraine: The patient's symptoms could also suggest a migraine triggered by the head injury. Migraines can cause severe headaches, nausea, and sensitivity to sound, which might be perceived as ringing in the ears.
• Inner Ear Injury: The fall could have caused an inner ear injury, leading to symptoms like vertigo, nausea, and tinnitus (ringing in the ears). This would be a consideration, especially if the patient reports any balance issues or vertigo.

Do Not Miss Diagnoses

• Subdural Hematoma or Other Intracranial Hemorrhage: Although less likely, it's crucial not to miss a potentially life-threatening condition like an intracranial hemorrhage. Symptoms can sometimes be delayed and may include headache, nausea, and in severe cases, alterations in consciousness.
• Basilar Skull Fracture: This could present with symptoms like headache, nausea, and possibly tinnitus or hearing changes due to the fracture's proximity to the inner ear structures.
• Meningitis: If the fall resulted in a basilar skull fracture that compromised the dura mater, there's a risk of meningitis, especially if there are symptoms like fever, stiff neck, or severe headache.

Rare Diagnoses

• Perilymphatic Fistula: A rare condition where there's an abnormal connection between the inner and middle ear, potentially caused by trauma. Symptoms can include vertigo, hearing loss, and tinnitus.
• Temporal Bone Fracture: While not the most common injury from a fall, a temporal bone fracture could explain the patient's symptoms, especially if there's associated hearing loss or facial weakness.

Given the patient is being seen on a virtual visit, it's essential to carefully assess the symptoms and potentially arrange for an in-person evaluation or imaging studies if there's any suspicion of a more severe condition. The patient should be advised to seek immediate medical attention if symptoms worsen or if new symptoms develop, such as severe headache, confusion, or difficulty walking.