• Initial Acute Concussion 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:*

  • 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*
  • GCS < 15*
  • Concussion History*

  • MEDICATIONS:

  • Anticoagulants:*
  • Anticoagulants:*

  • 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:*

  • Oculomotor: PERRL   

          

    Accommodation   Right:   Left      

    Convergence NPC      


  • Cardinal Planes of Gaze (III, IV, and VI) Smooth Pursuits*
  • Trigeminal*
  • 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*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Mild Traumatic Brain Injury (MTBI) / Concussion

    The patient has been diagnosed with a Mild Traumatic Brain Injury (MTBI) / Concussion. MTBI can be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. MTBI typically results in the rapid onset of short-lived impairment of neurological function that may resolve spontaneously. In some cases, signs and symptoms evolve over a number of minutes to hours. Acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury. As such, no abnormalities may be seen on standard structural neuroimaging (McCrory et al. 2017). 

    MTBI can result in a range of clinical signs and symptoms that may or may not involve loss of consciousness (LOC). In fact, only about 10% of concussions (MTBI) involve LOC. Resolution of the clinical and cognitive features typically follows a sequential course. In some cases symptoms may be prolonged (McCrory et al. 2017). When symptoms are prolonged greater than 30 days, the diagnosis should evolve to Persistent Concussive Symptoms (PCS).

    The following represents the Diagnostic Criteria for evaluation of MTBI:


    Mechanism of Injury

    Any one of the following symptoms (Acute Concussion Evaluation [ACE], Geioia et al, 2006):

    Physical: Headache, nausea, vomiting, balance problems, dizziness, visual problems, fatigue, sensitivity to light (photophobia), sensitivity to noise (phonophobia), and numbness/tingling.

    Cognitive:     Feeling mentally foggy, feeling slowed down, difficulty concentrating, and difficulty remembering.

    Emotional:     Irritability, sadness, more emotional, nervousness.

    Sleep:      Drowsiness, sleeping less than usual, sleeping more than usual, trouble falling asleep.

    In this case, the patient was administered the Symptom Severity Score questionnaire. The Symptom Severity Score can be utilized as an outcome measure to track the patient's MTBI recovery. In this case, neurologic evaluation was performed in order to assess the need for neuroimaging to exclude a more severe brain injury (e.g., structural abnormality). 

    It should be noted that the following factors are predictors for prolonged recovery (McCrea et al. 2013; Rabanowitz et al. 2015):

    Pre-existing Anxiety
    Depression
    High Symptoms Scores
    Older Age
    Female
    Lack of Patient Education Following Injury
    Missed Diagnosis by HCP

    Therefore, in this case the patient was appropriately diagnosed and educated on MTBI's (McCrea et al. 2013).

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