Hot Seat #250: Bogged Down
Posted on: October 28, 2025, by : Brittany Fitzpatrick
Case by David Branson, CNH PEM Fellow
7 yr old previously healthy M presenting for 2nd visit w scalp swelling after head trauma. Roughly 2 weeks ago, he was at school when he ran into a piece of playground equipment while playing tag, hitting his head on the equipment. He did not initially say anything, but parents noticed head swelling roughly 1 week later which prompted ED visit.
At the initial visit, his exam showed boggy tenderness over R temporoparietal scalp from midline to almost hairline, no skin lesions, and a normal neuro exam. CT was done which showed large scalp hematoma but no underlying fracture. Platelets and coags normal. The planned for PCP follow up +/- concussion clinic.
Today- they noticed increased scalp swelling, and had a brief episode of lightheadedness and neck pain which prompted a return to the ED.
Vitals: 98% on RA, T 36.8C, HR 106, RR 22, no BP
Physical Exam
General: Alert
Neurologic: GCS 15, appears comfortable, normal speech, A&O x4. Normal neuro exam. No dizziness, normal gait. Reports he is no longer having any pain or lightheadedness.
Skin: warm, intact
Head: Boggy fluctuance most noticeable over the right side of scalp extending from R parietal scalp over forehead and some mild fluctuance noted over L frontal parietal scalp. On palpation, fluid shifts across the midline. mild tenderness to palpation but no erythema, warmth, or drainage. There is a circular hypopigmented lesion over forehead with no erythema of scalp, no alopecia, no overlying erythema or inflammatory changes or signs of folliculitis over scalp
Neck: cervical spinous processes non-tender to palpation, normal ROM for neck.
ENMT: oral mucosa moist
Cardiovascular: regular rate and rhythm
Respiratory: lungs are clear to auscultation, respirations are non-labored
GI: soft, generalized tenderness to palpation
MSK: moves all extremities.
Back: nontender
Labs: Hgb 11.1, Hct 32.7, Plt 435. PT 14.3, PTT 33.3, INR 1.1.
US: IMPRESSION:
* Redemonstration of patient’s known right frontoparietal subgaleal hematoma
without sonographic evidence of active internal flow within the visualized
portions.
Head CT:
No Intracranial hemorrhage. No Fracture. Ongoing enlargement of scalp hematoma. (Further investigation is warranted for underlying coagulopathy or underlying genetic disorder of connective tissues given relatively minor trauma).
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I’ve seen large subgaleal hemorrhages “grow” in size after a week or two as the hematoma “liquefies.” Often the patient presents with a very boggy scalp — like a bag of water or jelly. This can be part of the normal healing process, but understandably can be anxiety provoking.