What assessment and labs are indicated for a 19-year-old male presenting with dizziness, claminess, shakiness, bloody nose, photophobia, fatigue, and bilateral ear impaction?

Assessment and Laboratory Workup for Post-Concussion Syndrome with Bilateral Cerumen Impaction

This 19-year-old male presents with classic post-concussion syndrome following a snowboarding injury, and the bilateral ear impaction must be cleared immediately to complete an accurate neurologic assessment. 1

Immediate Clinical Actions

Cerumen Removal (Priority #1)

• Remove bilateral cerumen impaction before proceeding with further evaluation, as impacted cerumen can cause dizziness, affect hearing assessment, and obscure the physical examination needed to evaluate for concussion complications 1, 2
• After cerumen removal, reassess for nystagmus, hearing changes, and vestibular symptoms 2, 3

Post-Concussion Assessment Battery

The symptom constellation—dizziness, photophobia, fatigue, difficulty concentrating, and autonomic symptoms (clamminess, shakiness)—represents classic concussion presentation 1:

• Complete the Postconcussion Symptom Scale to document baseline severity across all 22 symptoms including headache, dizziness, light sensitivity, fatigue, difficulty concentrating, and sleep disturbances 1
• Assess for retrograde and anterograde amnesia by asking specific questions about events immediately before and after the snowboarding incident 1
• Document loss of consciousness duration if it occurred (though LOC occurs in <10% of concussions) 1

Physical Examination Components

Neurologic Examination

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central vestibular causes, though this is most useful in acute vestibular syndrome rather than episodic symptoms 2, 3, 4
• Assess for focal neurologic deficits, particularly cranial nerve function 1, 2
• Evaluate gait and balance 1, 3
• Document the mild conjunctival injection noted on exam, which could represent photophobia-related eye strain or require consideration of other causes 1

Vestibular Testing

• Perform Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV), which can develop post-trauma and presents with brief episodic vertigo triggered by head movements 1, 2, 3
• BPPV is specifically associated with head trauma and could explain the nocturnal dizziness episodes when changing head position 1

Epistaxis Evaluation

• The single episode of epistaxis warrants documentation but is likely incidental unless accompanied by other concerning features 1
• Assess nasal mucosa for trauma, dryness, or other bleeding sources 1

Imaging Decisions

When Imaging is NOT Indicated

• No imaging is required for uncomplicated concussion with typical post-concussive symptoms and normal neurologic examination 1, 2
• The 2-week timeframe with persistent but stable symptoms does not mandate imaging 1, 2

Red Flags Requiring MRI Brain Without Contrast

Order MRI if any of the following develop 2, 5:

• Focal neurologic deficits beyond expected concussion symptoms
• Progressive worsening of symptoms rather than gradual improvement
• Severe or worsening headache
• Repeated vomiting
• Seizures
• Altered mental status beyond expected "fogginess"
• Inability to stand or walk (beyond mild balance issues)
• Downbeating nystagmus or other central nystagmus patterns

Current Clinical Picture

• This patient does NOT currently meet criteria for neuroimaging based on the symptom pattern of gradual improvement with episodic nocturnal dizziness and no focal deficits 1, 2

Laboratory Testing

Not Routinely Indicated

• No laboratory tests are indicated for uncomplicated post-concussion syndrome 1, 3, 6
• CBC, metabolic panel, and other routine labs have no role in concussion diagnosis or management 3, 6

Consider Labs Only If:

• Symptoms suggest alternative diagnosis (e.g., anemia if severe fatigue persists, thyroid dysfunction if symptoms don't improve) 3, 6
• Medication management requires monitoring 3

Audiometric Testing

Indications for Formal Audiometry

• Obtain comprehensive audiologic examination after cerumen removal if hearing complaints persist, particularly given the unilateral epistaxis which raises consideration of temporal bone injury 2
• Asymmetric hearing loss would warrant MRI to evaluate for vestibular schwannoma or other pathology, though this is unlikely in trauma context 1, 2

Follow-Up Strategy

Symptom Monitoring

• Reassess with Postconcussion Symptom Scale at each visit to track progress toward resolution 1
• Most concussion symptoms resolve within 7-10 days, though 10-15% have persistent symptoms beyond 3 weeks 1
• Mental fogginess may predict slower recovery 1

Return Precautions

Instruct patient to return immediately for 1, 2:

• Worsening headache or new severe headache
• Repeated vomiting
• Seizure activity
• Increasing confusion or drowsiness
• Focal weakness or numbness
• Vision changes beyond photophobia
• Inability to walk

Common Pitfalls to Avoid

• Do not dismiss persistent dizziness as purely psychological—post-traumatic BPPV is common and treatable with canalith repositioning 1, 2
• Do not order CT head for uncomplicated concussion—it has extremely low yield (<1%) and exposes the patient to unnecessary radiation 2
• Do not prescribe vestibular suppressants (meclizine, dimenhydrinate) as they impair central compensation and prolong recovery 3, 6
• Do not clear the patient for contact sports or high-risk activities until completely asymptomatic at rest and with exertion 1

Treatment Recommendations After Assessment

If BPPV Confirmed on Dix-Hallpike

• Perform Epley maneuver immediately with 80-90% success rate 2, 3, 6
• No medications needed for BPPV 2, 6

General Concussion Management

• Cognitive and physical rest initially, then gradual return to activities as tolerated 1
• Avoid bright lights and screens if photophobia persists 1
• Vestibular rehabilitation therapy if symptoms persist beyond 3-4 weeks despite appropriate initial management 2, 6