• Initial PCS Encounter

  • Date Of Injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Vitals:

    Height:   *   

    Weight:   *   

    Orthostatic Intolerance:

    Supine (2 Min): 
    BP    *      /   *       Heart Rate:   *   

    Stand (2 Min): 
    BP   *    /     *        Heart Rate:   *   

  • HISTORY

  • Direct Head Trauma*

  • Loss of Consciousness:
       *   

    Estimated Time   *   

  • Amnesia:

    Retrograde:                     

    Anterograde:                 

  • Current Symptoms:

    Symptom Severity Score:      /132     

    # Symptoms Present:     /22

  • Exertion:

  • Physical Activity: Symptoms Worsen*
  • Cognitive Activity: Symptoms Worsen*

  • RED FLAGS:  

  • Report / Evidence of Slurred Speech*
  • Severe / Worsening HA*
  • Can't Recognize People*
  • Decreasing Consciousness*
  • Seizures*
  • Increasing Confusion / Irritability*
  • Increasing Drowsiness*
  • Signs of Skull Fracture*
  • Vomiting x 2 Since Injury*
  • Unusual Behavior Change*
  • GCS < 15*
  • Concussion History*

  • MEDICATIONS:

  • Anticoagulants:*
  • Antiplatelets:*

  • COMPLICATING FACTORS:

  • Behavioral Disorder*
  • History of Headaches*
  • History of Anxiety:*
  • History of Depression*
  • History of Sleep Disorder*
  • History of Mental DX*

  • CLINICAL EXAMINATION

  • Observation Laceration / Contusion / Erythema*
  • Speech Dysphagia (difficulty with speech): Dysphonia (unable to sustain tone/volume): Dysarthria (words not formed properly):*
  • Mental Status Alert & Oriented x 4*
  • Skull Fracture Signs Battle Sign / Racoon Eyes CSF (Otorrhea or Rhinorrhea) Hemotympanum*
  • Palpation (Focal Tenderness)*

  • CRANIAL NERVES:

  • Olfactory*
  • Optic Visual Acuity*
  • Optic Confrontation:*
  • Cardinal Planes of Gaze (III, IV, and VI) Smooth Pursuits*

  • Oculomotor: PERRL   


       *   


    Accommodation        

    Convergence NPC       

       


  • Trigeminal*
  • Facial*
  • Vestibulocochlear (Hearing)*
  • IX and X*
  • Spinal Accessory*
  • Hypoglossal*

  • PYRAMIDAL TRACT

  • Pronator Drift*
  • Hoffman’s*

  • CEREBELLAR

  • Finger-Nose*
  • Finger-Finger*
  • Romberg’s*
  • Tandem Gait*
  • Coordination*
  • Rapid Alternating*

  • DIAGNOSES (ICD-10)

  • Concussion W/O LOC (Initial Visit) S06.0X0A*
  • Concussion W/ LOC < 30 Min (Initial Visit) S06.0X1A*
  • Concussion W/ LOC Unspecified Duration (Initial Visit) S06.0X9A*
  • Persistent Concussive Symptoms (PCS)AKA Post Concussion Syndrome F07.81*
  • Convergence Insufficiency H51.11*
  • Dizziness R42*
  • BPPV H81.10*

  • PLAN / RECOMMENDATIONS

  • Schedule:*
  • Prescribed:*
  • Psychological Complicating Factors Present*

  • Time: Today, I spent   *  minutes reviewing the patient’s current status, outcome measures, performing an MTBI neurologic evaluation, discussing my recommendations, documenting my findings and completing the chart note. The patient indicated an understanding of our discussion and we will implement the above treatment plan.

  • Tests Reviewed CPT*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Persistent Concussive Symptoms (PCS)

    The patient is greater than 30 days out from the onset of the Concussion/MTBI.  As such, the concussion has progressed to Persistent Concussive Symptoms (PCS) (previously known as Post Concussion Syndrome).  At this point, persistent symptoms typically do not reflect a single pathophysiologically entity, but describes a constellation of nonspecific posttraumatic symptoms that may be linked to coexisting and/or confounding factors, which did not necessarily reflect ongoing physiological injury to the brain (McCrory at al.  2017).


    The International Classification of Diseases (ICD-10) defines PCS as concussions in which symptoms persist greater than 30 days with the patient continuing to experience at least 3 of the following symptoms:

    Headache
    Dizziness
    Fatigue
    Irritability
    Sleep Problems
    Concentration Problems
    Memory Problems
    Problems tolerating stress/emotion/alcohol

    The patient satisfies the ICD-10 PCS criteria. There are multiple studies which report PCS can occur in greater than 30% of concussions.


    At this point, treatment should be individualized and target specific based on medical, physical, and/or psychosocial factors identified on assessment.  There is evidence to support the following (McCrory et al. 2017):


    Individualized symptom limited aerobic exercise program in patients with persistent postconcussive symptoms associated with autonomic instability or physical deconditioning.

    Targeted physical therapy program in patients with cervical spine or vestibular dysfunction.

    If necessary, a collaborative approach including cognitive behavioral therapy to deal with any persistent mood or behavioral issues.

    Unfortunately, the most common non-pharmacologic prescription for concussions is "rest" ("always" or "often" recommended by the majority of practitioners). Many practitioners are not recommending rehabilitation (Mannix et al. 2019). 


    At this point, the goal for treating PCS is determining what is causing their symptoms and treat/rehabilitate those mechanisms.  It typically takes at least a few visits to determine the true cause(s) of the patient's symptoms. 


    Visit 1: History, neurologic evaluation, and education.

    Visit 2: Buffalo Concussion Treadmill Test

    Visit 3: Visual, Vestibular (VOMS)

    Visit 4: Cervicogenic PCS Exam


    There are 5 Main Causes of PCS:


    Physiologic (Blood Flow):  This type of concussion will be assessed via the Buffalo Concussion Treadmill Test.

    Metabolic / Inflammatory / Hormonal:      The patient will be given a Concussion Recovery Diet. Exercise will help this etiology as well.

    Vestibulo-Ocular:      Will assess with vestibulo-ocular testing, and if necessary, the patient will be started on vestibulo-ocular rehabilitation.

    Cervicogenic:     There is known overlap between cervical injury and concussion symptomatology. The cervical spine will be assessed, and if necessary, cervical treatment / rehabilitation will be implemented.

    Psychological:      This type of concussion can be contributed by depression, anxiety, cognitive fatigue, poor concentration, and misattribution of symptoms ("Good Old Boy Days"). The patient will be counseled on the importance of proper sleep hygiene and appropriate exercise. If deemed necessary, the patient will be referred for Cognitive Behavioral Therapy, psychologic counseling, and/or Mindfulness / Meditation.

    Lastly, it is most important the patient understands that their brain is not "damaged". Patient was instructed that symptoms are "OK". As the causative factors behind the symptoms are addressed, they should recover. "Fear Avoidance" will be discussed and the importance of thinking positively.


    The patient’s outcome measures (Symptom Severity Score, # of symptoms, and evaluations) will be assessed at regular intervals. 

  • C 2022 First Care Concussion Clinic, LLC

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