Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Date of injury (concussion)
Mechanism of injury (e.g., sports injury, fall, motor vehicle accident)
Loss of consciousness (LOC) (yes/no, duration if present)
Post-traumatic amnesia (PTA) (yes/no, duration if present)
Presenting symptoms (select all that apply):
Headache
Dizziness
Nausea and vomiting
Balance problems
Difficulty concentrating
Sensitivity to light or noise
Fatigue
Sleep disturbances (difficulty falling asleep, staying asleep)
Irritability
Emotional lability (mood swings)
II. Past Medical History:
Previous concussions (yes/no, number, details if available)
Learning disabilities or attention deficit hyperactivity disorder (ADHD) (yes/no)
Migraine headaches (yes/no)
Medication use (anticoagulants, blood thinners)
III. Social History:
Sports participation (type of sport, level of competition)
Work or school environment (potential for head injury or exposure to hazards)
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Neurological exam:
Orientation to time, place, and person
Mental status (alertness, confusion)
Coordination (gait, balance)
Ocular motor function (pupils equal, reactive to light)
Cranial nerve exam (grossly intact)
Cognitive testing (if available): Briefly mention any specific tests used and results (e.g., SCAT5)
V. Assessment:
Concussion (acute, subacute, chronic – based on symptom duration)
Risk factors for prolonged recovery (e.t., history of multiple concussions, pre-existing learning difficulties)
VI. Plan:
Education:
Patient and family education on concussion symptoms, recovery process, and return to play/work/school guidelines.
Importance of cognitive and physical rest.
Signs and symptoms requiring urgent evaluation (worsening headache, vomiting, confusion, seizure)
Medication:
Consider medications for specific symptoms (e.g., pain relievers for headache, anti-emetics for nausea)
Follow-up:
Schedule follow-up appointments to monitor symptom resolution and cognitive function.
Consider referral to a sports medicine physician or concussion specialist for complex cases.
VII. Notes:
Include any additional observations or concerns, such as emotional well-being, sleep hygiene, and potential need for accommodations at school or work.
VIII. Resources:
Consider providing patient education materials on concussions from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), Brain Injury Association of America).