What is the diagnosis and recommended next steps for a 22-year-old female with a 3-day history of cough and colds, thick green nasal discharge, headache, difficulty breathing, recent head trauma, dizziness, and specific physical and mental examination findings?

Dual Diagnosis: Acute Viral Upper Respiratory Infection with Traumatic Brain Injury Requiring Urgent Neurological Evaluation

This patient requires immediate neurological imaging and evaluation for traumatic brain injury, as the loss of consciousness, cognitive impairment, and abnormal neurological findings supersede the management of her viral respiratory symptoms.

Primary Concern: Traumatic Brain Injury

Critical Red Flags Present

The neurological examination reveals multiple concerning findings that mandate urgent intervention:

• Loss of consciousness for 5 minutes following blunt head trauma is a significant indicator of potential intracranial injury 1
• Impaired short-term memory (unable to recall 3 words after 5 minutes) suggests cognitive dysfunction consistent with concussion or more severe brain injury 1
• Recurrent episodes of severe dizziness and headache ("crushing" quality, lasting 2-3 minutes, occurring 3 times) indicate possible increased intracranial pressure or evolving intracranial pathology 1
• Hyperreflexia (3+ patellar reflexes bilaterally) may indicate upper motor neuron involvement 1
• Dysmetria on finger-to-nose testing suggests cerebellar dysfunction or diffuse brain injury 1
• Lateralizing Weber test (to left ear) indicates either conductive hearing loss from trauma or sensorineural involvement 1

Immediate Next Steps for Head Trauma

Obtain urgent non-contrast head CT scan to rule out intracranial hemorrhage (epidural, subdural, subarachnoid), skull fracture, or cerebral edema 1. Any patient with loss of consciousness following head trauma requires neuroimaging, and the presence of cognitive deficits and abnormal neurological examination makes this mandatory 1.

Consider neurosurgical consultation if imaging reveals any acute intracranial pathology, as this patient may require admission for neurological monitoring 1.

Assess for cervical spine injury given the mechanism of blunt trauma to the head - clinical examination should evaluate for midline cervical tenderness, and imaging may be warranted 1.

Secondary Diagnosis: Acute Viral Upper Respiratory Infection

Respiratory Component Assessment

The respiratory symptoms are consistent with an acute viral upper respiratory infection:

• Thick green nasal discharge with swollen turbinates indicates viral rhinosinusitis, but the 3-day duration is too short to warrant antibiotics 1
• Inspiratory stridor and expiratory wheezes are concerning findings that require immediate attention - stridor suggests upper airway narrowing that could progress to respiratory compromise 1
• Sharp pain with breathing may represent viral bronchitis or pleuritic chest pain 1

Critical Respiratory Management

The stridor requires immediate assessment for airway patency - this is not a typical finding in simple viral upper respiratory infection and may indicate laryngeal edema, epiglottitis, or severe laryngotracheitis 1.

Obtain pulse oximetry immediately to assess oxygenation status 1.

Consider chest radiograph to rule out pneumonia, given the presence of wheezing and difficulty breathing 1.

Appropriate Treatment for Viral Symptoms

No antibiotics are indicated for this viral syndrome, as the 3-day duration does not meet criteria for bacterial sinusitis (which requires >10 days of persistent symptoms or severe symptoms >3 consecutive days with fever >39°C and purulent discharge) 1, 2.

Supportive care only for the viral upper respiratory infection: analgesics (acetaminophen or NSAIDs) for pain and fever, adequate hydration, and rest 2.

Symptomatic relief measures include saline nasal irrigation, throat lozenges, and salt water gargles 1, 2.

Integrated Management Algorithm

Step 1: Stabilize and Assess Airway (Immediate)

• Evaluate stridor severity and respiratory distress
• Obtain pulse oximetry
• Ensure airway patency

Step 2: Neurological Emergency Evaluation (Urgent - Within 1 Hour)

• Non-contrast head CT scan
• Complete neurological examination documentation
• Consider cervical spine imaging if indicated

Step 3: Respiratory Workup (If Stable)

• Chest radiograph if respiratory distress persists
• No antibiotics for viral syndrome 1, 2

Step 4: Disposition Decision

• Admit for observation if any intracranial pathology on CT, persistent altered mental status, or respiratory compromise 1
• Neurosurgery consultation if imaging abnormalities present 1
• Close follow-up within 24 hours if discharged, with strict return precautions 2

Common Pitfalls to Avoid

Do not dismiss the neurological findings as simply related to viral illness - fever and headache from viral infection do not cause loss of consciousness, cognitive impairment, hyperreflexia, or cerebellar signs 1.

Do not prescribe antibiotics for this viral respiratory infection - the 3-day duration and clinical presentation do not meet criteria for bacterial sinusitis, and antibiotics cause more harm than benefit 1, 2.

Do not overlook the stridor - this is an atypical finding for simple viral upper respiratory infection and requires investigation for more serious airway pathology 1.

Do not send this patient home without neuroimaging - loss of consciousness with abnormal neurological examination mandates CT evaluation regardless of how "well" the patient appears 1.

Return Precautions

Instruct the patient to return immediately for:

• Worsening headache or new neurological symptoms
• Repeated vomiting
• Increasing confusion or difficulty staying awake
• Seizure activity
• Worsening respiratory distress or stridor
• High fever >39°C
• Inability to maintain hydration 2