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Assessment:
The patient exhibits signs and symptoms consistent with a concussion, including headache, dizziness, confusion, nausea, and sensitivity to light. There is no evidence of skull fracture or intracranial hemorrhage on imaging. The differential diagnosis includes post-concussion syndrome, cervical strain, and vestibular dysfunction.
Plan:
The patient is advised to rest with gradual return to normal activities based on symptom resolution. Cognitive rest, including limiting screen time and avoiding strenuous mental tasks, is recommended. Monitor for worsening symptoms such as severe headaches, vomiting, or loss of consciousness. Referral to neurology or a concussion specialist is considered if symptoms persist or worsen. Follow up in 1-2 weeks to reassess symptoms and recovery progress.
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