Wouldn’t it be nice to earn CME Credits for the research work you’re already doing?
Background: Our subject is a 16 year-old male American football linebacker (height: 183.3 cm., weight: 89 kg). In May 2011, our subject checked his blood pressure “as a joke” on an automated supermarket sphygmomanometer. His systolic pressure was 160 mm/Hg. He then visited a physician to investigate his hypertension as part of his sports physical. The physician did not clear him for sports because of his elevated blood pressure. He then consulted his family physician who referred him to a pediatric cardiologist. Our subject has a family history of hypertension on his paternal side. The subject indicated he occasionally experienced chest discomfort lasting a few seconds per episode. There was not a history of dependent edema, dyspnea with exertion, or syncope; however, he did have occasional orthostatic dizziness. He had a history of a significant concussion in 2008 while skate boarding. He experienced vision issues and prolonged symptoms following this event. In June 2011, his cardiologist prescribed an ACE inhibitor, lisinopril, starting with 5 mg daily to control his hypertension. In July 2011, in spite of a still slightly elevated blood pressure, he was cleared to participate in a summer football camp. He sustained another concussion during this camp and was removed from competition for the week. When fall practice began nearly a month later (August 2011), he denied any post-concussion symptoms. He sustained another concussion during the first week of formal practice with severe symptoms. Following this concussion, he “came clean” admitting the symptoms from the camp concussion had not previously resolved. When school started, his friends noticed a difference in his personality with mood swings and increased emotions. He had difficulty hard time remembering conversations with his friends. Because of his inability to concentrate, he dropped his two most difficult classes. Other physical symptoms, such as headache, also continued. Differential Diagnosis: essential hypertension, malignant hypertension, concussion, hypertrophic cardiomyopathy, renal artery stenosis Treatment: When the initial dose of lisinopril was not effective, the dose was increased to 10 mg and finally to 20 mg. In September 2011, the lisinopril was still not effective in lowering the blood pressure. A switch to a calcium-channel blocker, amlodipine (5 mg daily) was made. Amlodipine has been effective in controlling his hypertension. We noted a relationship in the reduction of his headache symptoms (one month post-concussion) and the lowering of his blood pressure with the amlodipine. His echocardiogram revealed no cardiac abnormalities. His pediatric cardiologist referred him to a nephrologist for two separate ultrasound evaluations. Both of which revealed no abnormalities of his kidneys that might be causing the hypertension. An imPACT neuropsychological test was administered on November 3, 2011 with results equal to his 2009 baseline. Uniqueness: It is the concurring opinion of his physicians that his hypertension may have played a role in the exacerbating his concussion symptoms. This drives home the point that athletic trainers need to consider other underlying issues that can intensify concussive symptoms. In his case, his hypertension may have been issue in prolonging his headache and other concussive symptoms. Conclusions: He was cleared to return to football in November 2011, but did not return since only two games remained in the season. His headache and concentration difficulties lasted nearly two months. His cardiologist diagnosed his hypertension as essential and recommended controlling with continued exercise, proper nutrition, and medication. With his concussion symptoms gone and blood pressure under control, he had been working out regularly and planning to return to football for the 2012 season. However, there are some unresolved health issues including his multiple concussions and chest pain episodes that need to be addressed.