A patient who fell on a ski jump and sustained a mild traumatic brain injury now has foggy feeling, difficulty concentrating on math and reading, photophobia, phonophobia, and intermittent flashing headlights without focal neurologic deficits; what is the most likely diagnosis and recommended management?

Diagnosis: Mild Traumatic Brain Injury (Concussion) with Post-Concussive Symptoms

This patient has sustained a mild traumatic brain injury (mTBI/concussion) and is now experiencing post-concussive symptoms including cognitive dysfunction ("foggy" feeling, difficulty concentrating), photophobia, and phonophobia—all classic manifestations that typically resolve within days to weeks but require active management and monitoring. 1

Clinical Presentation Analysis

The symptom constellation is entirely consistent with mTBI:

• Cognitive symptoms: Mental fogginess and difficulty with concentration/reading are recognized predictors of slower recovery and are part of the early-phase post-traumatic disorder 1, 2
• Photophobia and phonophobia: Light and noise sensitivity are cardinal features of post-concussive syndrome 3, 2
• Visual disturbances: The flashing headlights phenomenon represents visual processing deficits common in mTBI affecting the frontal and temporal lobes 3
• Initial headache and nausea: The triad of headache, nausea, and dizziness at presentation identifies patients with 50% risk of developing persistent post-concussion syndrome at 6 months 1, 3

Immediate Management Recommendations

No Hospital Admission Required

Hospital admission is not indicated for this patient with persistent post-concussive symptoms in the absence of red flag symptoms (no worsening headache, no repeated vomiting, no focal neurologic deficits, no altered consciousness). 4

Active Recovery Protocol (Not Strict Rest)

Strict rest beyond 48-72 hours is contraindicated as it may actually delay recovery. 4 Instead:

• Begin sub-symptom threshold aerobic exercise immediately at 60-70% of maximum heart rate for 15-20 minutes daily, gradually increasing as tolerated 4
• Implement partial cognitive rest: Screen time limited to 30-minute intervals with breaks 4
• Modify academic activities: Shortened school days with reduced workload, not complete avoidance 4

Specialist Referral Required

This patient requires referral to a concussion specialist or sports medicine physician because symptoms are persisting beyond the acute injury period (now 4-5 days post-injury) and cognitive symptoms are interfering with function. 4 The combination of cognitive dysfunction and sensory sensitivities may benefit from:

• Vestibular rehabilitation 4
• Targeted cognitive interventions 4
• Interdisciplinary coordinated care 4

Critical Red Flags for Emergency Return

Provide written and verbal instructions to return to the emergency department immediately for: 4, 5

• Repeated vomiting or inability to hold down fluids
• Worsening or severe headache
• Increasing confusion or memory problems
• Focal neurologic deficits (weakness, numbness, vision changes)
• Abnormal behavior or personality changes
• Increased sleepiness or loss of consciousness
• Seizures

Prognosis and Expected Recovery

Most patients (80-85%) recover completely within 3 months. 4 However, this patient has risk factors for prolonged recovery:

• High initial symptom burden (headache, nausea, cognitive symptoms) 1, 3
• History of prior concussion (mentioned by relative) 2
• Cognitive symptoms persisting beyond 72 hours 1

Persistent symptoms beyond 3 months occur in 15-20% and constitute post-concussion syndrome, which would require more intensive multidisciplinary management. 4, 2

Common Pitfalls to Avoid

• Do not prescribe complete cognitive and physical rest—this is outdated management that delays recovery 4
• Do not dismiss symptoms as "just a concussion"—mental fogginess is a validated predictor of slower recovery requiring active intervention 1
• Do not delay specialist referral—early intervention for persistent symptoms (>3-5 days) improves outcomes 4
• Do not allow return to high-risk activities (skiing, contact sports, driving in challenging conditions) until symptom-free and cleared by specialist 4

Symptom-Specific Management

For the specific symptoms present:

• Photophobia/phonophobia: Gradual exposure therapy, sunglasses for outdoor activities, quiet environments initially 2
• Cognitive dysfunction: Cognitive rest intervals, avoid multitasking, use written lists and reminders 4
• Visual disturbances: Ophthalmology or neuro-ophthalmology evaluation if symptoms persist beyond 1 week 3