Differential Diagnosis for Mild Head Trauma from Assault

Given the scenario of a patient seeking evaluation after mild head trauma from an assault, with a normal exam, and considering that the CPT code for "assault" cannot be used as the primary code, the differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Concussion: This is the most likely diagnosis given the context of mild head trauma. A concussion, also known as a mild traumatic brain injury (mTBI), is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull. Though the patient has a normal exam, concussions can present with normal initial examinations but still have significant symptoms or develop them later.
• Other Likely Diagnoses
  • Post-concussive syndrome: This condition refers to the persistence of concussion symptoms beyond the expected recovery period, which can vary but often is considered to be beyond a couple of weeks. Symptoms can include headaches, dizziness, irritability, and problems with concentration and memory.
  • Cervical strain: The mechanism of injury from an assault could also result in strain to the neck muscles, leading to pain and stiffness.
  • Anxiety or acute stress disorder: The psychological impact of being assaulted should not be overlooked, and patients may present with anxiety or symptoms of acute stress disorder following the traumatic event.
• Do Not Miss Diagnoses
  • Subdural hematoma or other intracranial hemorrhage: Although the patient has a normal exam, the possibility of a slowly expanding intracranial hemorrhage cannot be ruled out without imaging, especially if there are risk factors for bleeding or if the mechanism of injury was severe.
  • Skull fracture: A fracture could be present even with a normal neurological examination, and certain types of fractures (e.g., those involving the sinuses or the temporal bone) can have specific complications.
  • Cervical spine injury: The force of an assault could potentially injure the cervical spine, and missing such an injury could lead to serious neurological consequences.
• Rare Diagnoses
  • Epidural hematoma: This is a less common type of intracranial hemorrhage but is critical to diagnose promptly due to its potential for rapid deterioration.
  • Arteriovenous fistula or carotid artery dissection: These vascular injuries are rare but can occur after trauma to the neck and can have severe consequences if not identified and treated.
  • Leptomeningeal cyst: A rare complication of skull fractures, where there is a tear in the dura mater, allowing cerebrospinal fluid to leak and form a cyst.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and potentially, diagnostic imaging to ensure that no serious condition is overlooked.