Concussion, also known as mild traumatic brain injury (TBI), is an injury to the head as a result of trauma to the head by an externa force causing brain tissue stress (Scorza & Cole, 2019). Concussion is a major national health concern and accounts for 80-90% TBIs; due to lack of unified objective measure or treatment, clearance to return to normal activity level, is left to expert guidelines, clinical judgement (Scorza & Cole, 2019).
Concussion is the most common sport injury in athletes caused by a direct hit to the head, neck, face, or elsewhere causing a temporary acute neurological impairment that resolves rapidly; however, some symptoms may linger from minutes to hours or days (Scorza & Cole, 2019). Most cases of concussions does not result in a loss of consciousness, but it temporarily affect the person judgement, speech, balance, judgment, and muscle coordination (American Association of Neurological Surgeons [AANS], 2024). Furthermore, after the injury, the person may complain of temporary memory loss and forgetfulness (AANS, 2024).
Most people quickly recover from a concussion; however, in some people symptoms last longer and can lead to some complication such as chronic headache, seizures, slurred speech, loss of consciousness, and coma (AANS, 2024). Recognizing early symptoms of concussion by providers is important to teach and guide patient throughout this period to improve patient outcomes, prevent reinjuries, and minimizing its complications. Ealy diagnosis of concussion is very important for adequate patient care and monitoring.
Topic review and selection of rationale
Concussion is a mild TBI, but if not treated properly, it can lead to serious consequences. Concussion led to more than 800,000 emergency department visits and treatment in the U.S, with 300,000 sports-related concussion a year in the US (AANS, 2024). It is estimated that all athletes that participate in contact sports will suffer a concussion within 5 years of sport participation (AANS, 2024). Furthermore, up to 20% of player, will suffer multiple concussions during their sport participation (AANS, 2024). As mentioned before, concussion can lead to many complications that can last for several months and can have a negative impact on the patient and their families; the main symptoms that persist are headache, dizziness, and fatigue; mood and personality changes, memory and concentration issues, and insomnia (AANS, 2024). Preventing injuries and minimizing its impact are crucial to patients’ health and recovery. Prevention involves always wearing headgears and helmets while participating in sports, close supervision of young children, perform safety checks prior to playing or driving, remove hazards that can cause falls or injuries to name a few (AANS, 2024).
Key Concepts Evaluation
Concussion is a condition that involve release of chemicals and neurotransmitter as a result of mechanical force on the brain; intracellular potassium release led to depolarization of neurons which accounts for some of patient’s symptoms, such as headache (Romeu-Mejia et al., 2019). The release of neurotransmitters, and intracellular sodium and calcium, because of depolarization causes cell damage and death (Romeu-Mejia et al., 2019). Following a concussion, cellular metabolism demand increase causing increase conversion of glucose to pyruvate which lead to production of reactive oxygen species; ROS and decrease blood flow led to anaerobic metabolism which results in excessive lactate accumulation and low ATP production (Romeu-Mejia et al., 2019). Furthermore, damage to neurons from the rapid head deceleration results in disruption of neuron transmission (Romeu-Mejia et al., 2019). Inflammation of neuron contribute to the concussion symptoms and its duration; systemic inflammation, elevation of high-sensitivity C-reactive protein are indicative of severity of concussion (Romeu-Mejia et al., 2019).
Description of multiple viewpoints
Numerous concussion clinical practice guidelines available from different organization, with one goal is to provide the best possible care for patient with complaint of concussion and improve their outcomes. I will concussion clinical guidelines from the American College of Emergency Physicians (ACEP) and Ontario Neurotrauma Foundation (ONF). ACEP concussion guideline is intended for patient with blunt head injuries or with a diagnosis of concussion. ACEP recommend provider to utilize the Canadian CT hear rule to determine the need for ordering imaging in adults with mild injuries to the head (Valente et al., 2023). If patient is taking anticoagulation, no need for CT head repeat, if initial CT was normal and patient neurological examination is at baseline (Valente et al., 22023) The rational is to decrease cost and amount of radiation a patient is expose to (Valente et al., 2023). The Canadian CT head injury rule only applies to patient with GCS of 13 or greater with either loss of consciousness, amnesia, or disorientation (Valente et al., 2023). The ONF, living concussion guideline, also uses the Canadian CT Head Rule to determine the need to obtain imaging in patient with mild TBI (ONF, 2024).
Both treatment guidelines recommend referral to specialist if patient lost consciousness during the injury or GCS less than 15; with majority of patient will only require follow up by primary care provider. Initial concussion management should be individualized based on patient symptoms severity and neurological exam finding.
Concussion Merit of Evidence
Since there are no medication specific for concussion or mild TB, treatment is administered for symptoms management only (Scorza & Cole, 2019). Most guidelines recommend physical and cognitive rest from 24 to 48 hours with gradual return to daily activity based on patient tolerance (Scorza & Cole, 2019). ACEP, ONF, and American Association of Neurological Surgeons all recommend rest and gradual return to activity of daily living, emphasizing on individualizing care. The Center for Disease Prevention and Control (CDC), recommend patient to avoid activities that can cause new head injury, inform family and friend of one’s feelings, inform the provider of medication safe to take, limit screen time, reduce lighting, and follow a regular sleep-wake schedule (CDC, n.d.). In a single randomized clinical trial studying the effect of reducing screen time in patient with mild traumatic brain injury who experienced post-concussion symptoms; the study found that symptoms duration decreased significantly by reduction of screen time (Rabaza et al., 2023). Another study also confirmed the findings that reducing screen time during recovery from concussion may reduce the duration of symptoms (Macnow et al., 2021).
Evaluation of Concussion Current Evidence-based Guidelines
While doing my research concussion current EBG although they are published from different organization, they are similar in term of assessment, imaging requirement, and post discharge treatment and follow-up. All the guidelines relies on Canadian CT head Rule to determine the need for imaging for adults and pediatric patients. All organization and studies confirm the importance of reducing screen time in the acute phase of concussion to reduce symptoms duration; they also recommend individualized care based on patients’ uniqueness. While rest is recommended by all organizations, length of rest is unclear. A randomized controlled trial titles “Implementation of active injury management in youth with acute concussion.” Found that youth who were prescribed physical activity and behavioral management within 72 hours of concussion their outcomes were improved when compared to those who were not (Thomas et al., 2022). The AAFP also recommend patient to be gradually returned to daily activity and in certain patient it may take longer based on the severity of the injury (Scorza & Cole, 2019).
Cultural, Spiritual, and Socioeconomic Considerations
In any treatment approach, providers must account for patient’s cultural and spiritual beliefs and use a holistic approach to treat and educate patient and their families on the acute phase of concussion, discharge instruction, reporting new symptoms, and follow up. Concussion is a traumatic event that disrupt brain function and can influence the patient’s physical and emotional status; and based on the length of symptoms it can have a negative impact on the patient well-being and daily function (Eagle et al., 2022). Suicide ideation is a major risk in patient post-concussion; providers, patient, and family must be aware of this to prevent harm to patient. Black, Hispanics, and multiracial race and ethnicity risk for suicide were higher than other races (Eagle et al., 2022). The study findings suggest that providers should take into considerations patient race, ethnicity when evaluation and treating youth with concussion (Eagle et al., 2022).
Standardized Procedure for Concussion
As mentioned previously, there is not one standardized procedure for concussion but overall, they all have some recommendations. Despite the mechanism of injury either a sport or non-sport related, the symptoms and assessment remain the same. Patient with concussions are treated in different sittings from emergency department, physician on the sport field, primary practice office. If I were to develop a standardized procedure for concussion my recommendation will be that all patient with concussion regardless of symptoms severity, need an evaluation by specialist at least one time. However, I recognize the difficulty of implementing that since accessibility to neurologist is very limited in primary sitting when compared to in patient settings. Another recommendation will be in patient with history of depression, they must be assessed for suicide risk and provided a plan to reduce suicide ideation or attempts.
Evidence Impact on Practice
Reflecting on my research regarding evaluation, treatment, education, and follow up of concussion, I will change the way I evaluate and educate the patient. Although the mechanism of head injury differ, the approach to evaluate and treat is same. Working in the emergency department, I recognize that many practitioners, not all, are not utilizing the Canadian CT Head rule and over order imaging. My approach will always be evaluating patient need for imaging using evidence based guidelines, taking into consideration risk vs benefit of added radiation to patients. Another impact this research will have on my practicing is recognizing that concussion or mild TBI disrupt brain function and I screen patient to determine risk for suicide and treat accordingly.
Conclusion
Concussion is a disruption of brain function, and its course can range from mild where symptoms resolve in less than 24 hrs. to severe that symptoms can linger affecting patient health and disrupting their lives. Providers must follow evidence-based guidelines to evaluate, treat symptoms if any, and provide a detailed discharge instruction, and ensure patient follow up. Care for patient with concussion must be approached in a holistic manner and if possible, a designated family member should be presents to assist patient. Close follow up is needed to prevent any complication such as increase in length of symptoms duration and increase in suicide risk. As a primary care specialty, relying on and utilizing referral process in a timely manner either to specialty or emergency department when warranted is a most.
References
American Association of Neurological Surgeons. (2024). Concussion. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Concussion
Center for Disease Prevention and Control. (n.d.). Traumatic brain injury & concussion discharge instruction. https://www.cdc.gov/traumaticbraininjury/pdf/tbi_patient_instructions-a.pdf
Eagle, S. R., Brent, D., Covassin, T., Elbin, R. J., Wallace, J., Ortega, J., Pan, R., Anto-Ocrah, M., Okonkwo, D. O., Collins, M. W., & Kontos, A. P. (2022). Exploration of race and ethnicity, sex, sport-related concussion, depression history, and suicide attempts in US youth. JAMA Network Open, 5(7). https://doi.org/10.1001/jamanetworkopen.2022.19934
Macnow, T., Curran, T., Tolliday, C., Martin, K., McCarthy, M., Ayturk, D., Babu, K. M., & Mannix, R. (2021). Effect of screen time on recovery from concussion. JAMA Pediatrics, 175(11), 1124–1131. https://doi.org/10.1001/jamapediatrics.2021.2782
Ontario Neurotrauma Foundation. (2024). Guideline for concussion & prolonged symptoms for adults 18 years of age or older. https://concussionsontario.org/
Rabaza, C., Piggott, C., Lyon, C., & Jarrett, J. B. (2023). Put down the electronics after a concussion? The Journal of Family Practice, 72(01). https://doi.org/10.12788/jfp.0534
Romeu-Mejia, R., Giza, C. C., & Goldman, J. T. (2019). Concussion pathophysiology and injury biomechanics. Current Reviews in Musculoskeletal Medicine, 12(2), 105–116. https://doi.org/10.1007/s12178-019-09536-8
Scorza, K. A., & Cole, W. (2019). Current concepts in concussion: Initial Evaluation and Management. American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2019/0401/p426.html
Thomas, D. G., Erpenbach, H., Hickey, R. W., Waltzman, D., Haarbauer-Krupa, J., Nelson, L. D., Patterson, C. G., McCrea, M. A., Collins, M. W., & Kontos, A. P. (2022). Implementation of Active Injury Management (AIM) in youth with acute concussion: A randomized controlled trial. Contemporary Clinical Trials, 123, 106965. https://doi.org/10.1016/j.cct.2022.106965
Valente, J. H., Anderson, J. D., Paolo, W. F., Sarmiento, K., Tomaszewski, C. A., Haukoos, J. S., Diercks, D. B., Diercks, D. B., Anderson, J. D., Byyny, R., Carpenter, C. R., Friedman, B., Gemme, S. R., Gerardo, C. J., Godwin, S. A., Hahn, S. A., Hatten, B. W., Haukoos, J. S., Kaji, A., … Vandertulip, K. (2023). Clinical policy: Critical issues in the management of adult patients presenting to the emergency department with Mild Traumatic Brain Injury. Annals of Emergency Medicine, 81(5). https://doi.org/10.1016/j.annemergmed.2023.01.014
Appendix A
ID: B.C. a 16-year-old, Caucasian, single male, DOB 1/1/2008. Alert and oriented to person, time, place, and situation. Accompanied by his parents. Patient and his parents are good historians.
Subjective
CC: “I have headache and I feel dizzy”.
HPI: This is a 16-year-old Caucasian male brought into the clinic today by his parents with complaint of headache, dizziness, and sensitivity to light and noise. Per patient while he was playing football, he got tackled, fell backward, and hit the back of his head against the floor x3 days ago. Patient was wearing a helmet at the time of injury. Patient denies loss of consciousness, blurry or double vision. Per parent, patient have been complaining of nausea, but have not vomited. Patient went to school today but due to “too much noise” had to leave school. Patient denies neck or back pain. Denies loss of bowel or bladder control. Last annual exam January 2024. Patient is up to date with all his childhood immunizations. Patient received 2 shots of COVID vaccine with 2 boosters, last booster April 2023. Influenza vaccine November 2023.
Past Medical History:
• Medical problem list: No past medical history
• Preventative care: Annual Exam 01/14/2024. Dental exam 12/24/2023
• Surgeries: No surgeries in the past
• Hospitalizations: No hospitalizations in the past
Allergies:
• No known allergies to medications
• No known allergies to food
• No allergies to latex
• No environmental allergies
Medications:
• Tylenol 650 PO every 6 hours as needed for pain.
• No over the counter medication
• No vitamins or herbal products
Family History:
• Mother: 39 years old with no medical issues
• Father: 40 years old with no medical issues
• Sibling: younger sister with no medical issues
• Maternal Grandfather: hypertension, hyperlipidemia.
• Maternal Grandmother: No medical issues
• Paternal Grandfather: hypertension
• Paternal Grandmother: hypothyroidism, osteoporosis
Social History:
• Chemicals: Denies vaping or smoking or chewing tobacco. Denies exposure to secondhand smoke.
• Diet/exercise: Decrease appetite with nausea. Runs track and play football.
• Sexual History: Did not address as parents were in the exam room and no concern currently.
• Current living situation: Live in a house with parents and sister.
Review of Systems:
● Constitutional: (-) change in weight (+) decrease appetite, (-) fatigue, (-) fever, (-) chills.
● Eyes: (-) blurry vision, (-) double vision, (+) light sensitivity.
● Ears: (-) ear exudate, (+) sensitivity to noise (-) difficulty hearing.
● Nose: (-) drainage. (-) tenderness, (-) loss of smell.
● Throat/neck: (-) throat pain, (-) pain/swelling of the neck, (-) voice changes.
● Cardiovascular: (-) chest pain (-) tenderness, (-) edema.
● Respiratory: (-) shortness of breath (-) cough.
● Neurologic: (+) occipital headache, (+) dizziness, (+) lightheadedness, (-) slurred speech, (-) seizures, (-) gait disturbances.
● Gastrointestinal: (-) abdominal pain, (+) nausea, (-) diarrhea.
● Genitourinary: (-) incontinence, (-) flank pain, (-) urinary retention.
Objectives
Vital Signs:
• HR: 76. BP: 108/63 Temp: 97.8 F. RR: 16 SpO2: 100 Pain: 4/10
• Height: 5’ 11” Weight: 150 lb. BMI: 20.9 BMI Percentile: 55%
- Labs: None ordered today.
Physical Exam:
• General survey/constitutional: Patient appears well groomed, dressed appropriate for the weather, and in no acute visible distress. He is alert and oriented x4. He walked to the examination room with normal gait, without any visible discomfort or difficulty walking. He is sitting on the chair upright without discomfort.
• Head: round, normocephalic, no externa trauma noted. No hematoma. Occipital tenderness present.
• GI/GU:
• Eyes: Positive light sensitivity. No eye discharge, edema, or redness. PERRLA. Bilateral Pupils +3
• Ear: No visible deformity to bilateral ears. No redness, bulging, or rupture to Bilateral tympanic membranes. Minimal cerumen impaction.
• Nose: Nose is midline, without deformity. No redness or swelling to turbinate. Mucosa is pink, with no crust or exudates.
• Throat/Mouth/Neck: No redness to back of throat. Tonsils are not visible. Uvula midline. No enlarged lymph nodes. Trachea is midline. Tongue is midline with no deviation.
• CV: S1/S2 present. No clicks, murmurs, gallops, or rubs auscultated.
• Pulmonary: clear lungs sounds. No wheezing, rales, friction rubs, or crackles present. No nasal flaring or accessory muscle use.
• Musculoskeletal: No tenderness when palpating the back and spine. No spinal step offs. Full range of motion noted.
• Neuro: CN I-XII all intact. No numbness or tingling. Gait is normal. No pronator drift. Negative Romberg test. Normal finger to nose test. Sensation and strength are grossly intact.
Cranial nerve I (olfactory): Patient denies loss of smell.
Cranial Nerve II (Optic): visual acuity 20/20 uncorrected to right, left, and bilateral eyes.
Cranial Nerve III (Oculomotor) Pupils constrict to direct light and consensually from 5mm to 3mm.
Cranial Nerve III, IV, VI (Oculomotor, Trochlear, and Abducens): 6 cardinals gaze were all normal with no nystagmus. No gaze deviation noted.
Cranial Nerve V (Trigeminal): sensation intact and equal to bilateral sides of face, able to open jaw against resistance without difficulty.
Cranial Nerve VII (Facial): No facial or eye drooping. Symmetrical smile. Symmetrical eyebrows when asked to raise them.
Cranial Nerve VIII (Vestibulocochlear): hearing is intact based on whisper test.
Cranial Nerve IX, X (Glossopharyngeal & Vagus): uvula rises when patient say “Ahh”, swallow without difficulty.
Cranial Nerve XI (Spinal Accessory): shoulder shrug bilaterally against resistance without weakness. Turn neck against resistance to right and left without difficulty or pain.
Cranial Nerve (Hypoglossal): Tongue is midline with no deviation. Able to move tongue side to side.
• Allergic/Immunologic: No allergies, no fevers, or hives.
Assessment
Differential Diagnosis:
- Concussion without loss of consciousness, initial encounter (S06.0X0A): headache, difficulty concentration, sensitivity to light.
a. Rationale: Common symptoms of concussion are confusion, headache, visual changes, nausea or vomiting, memory loss, ringing in the ear, difficulty concentration, light sensitivity, loss of taste or smell, difficulty sleeping (Agarwal et al., 2024). My patient symptoms started after a fall and striking his head. - Tension-type headache, unspecified, not intractable (G44. 209):
a. Rationale: tension type headache is a dull, aching headache that is aggravated with normal activity (Onan et al., 2023). Given patient light sensitivity and difficulty concentration, tension headache was ruled out. - Migraines with aura (G43.1):
a. Rationale: Migraine headache presents with sensitivity to light and sound, nausea and or vomiting (Onan et al., 2023). While my patient have all symptoms of migraines, due to no migraine history and patient symptoms developed after the trauma to the head, made me exclude this diagnosis.
Diagnosis: Concussion without loss of consciousness, initial encounter (S06.0X0A)
Plan
Diagnostic Plan:
• Based on the exam and patient presenting symptoms, diagnostic imaging is not required. If patient symptoms worsens or new symptoms develop, we will consider ordering a CT head or MRI. The American Association of Neurological Surgeons do not recommend performing routine MRI or CT to diagnose a concussion, as this imaging rarely show any changes and only expose the patient to unnecessary radiation (Agarwal et al., 2024).
Therapeutic Plan:
• Medication for headache and nausea:
o Tylenol 650-1000 mg 1 tab PO Q4-Q6 hours as needed for pain. Do not exceed 4000mg in 24hrs period.
o Ibuprofen 600 mg PO Q6 hours as needed for pain.
o Ondansetron 4mg PO Sublingual Q8 hours as needed for nausea and headache.
Rationale: headache associated with post traumatic injury can be treated with analgesics, NSAIDS, antiemetic agents such as ondansetron (Blumenfeld et al., 2022).
Referrals: No referral is needed at this time. However, if patient symptoms persist or worsens, referral to neurology will be discussed with family.
Education and Follow-up Plan:
• Patients get plenty of rest, avoiding electronics, social media, and team meetings until signs and symptoms of concussion are resolved (Agarwal et al., 2024).
• Patient should not return to play until all symptoms of concussion are resolved and cleared a healthcare provider (Scorza & Cole, 2019).
• Patient to be educated that there is no medication to treat concussion specifically, rather we will manage and treat the symptoms (Scorza & Cole, 2019).
• Can go to school for half a day or all day if tolerated.
• Patient and parents to seek emergency medical care if patient develop slurred speech, increase confusion, and or seizure activity (Agarwal et al., 2024).
• Turn off light and decrease auditory stimulation
• Follow-up in one week for symptoms reevaluation or sooner if needed.
Appendix B
ID: B.C. a 16-year-old, Caucasian, single male, DOB 1/1/2008. Alert and oriented x3.
Subjective
CC: “I am here for a follow-up”.
HPI: The patient is a 16-year-old Caucasian male presenting to the clinic accompanied by his father for a scheduled follow up. Patient was seen last week with complaint of headache, dizziness, and sensitivity to light and noise. Symptoms develop after a sport injury where patient was tackled and strike his head against the floor while playing football. Patient denies any symptoms currently. Per patient and father, patient have attended school the last two days and uses his laptop to do his homework 2-3 hours daily without any issues. Patient have not played sport with team, but have been practicing at home.
Past Medical History:
• Medical problem list: No past medical history
• Preventative care: Annual Exam 01/14/2024. Dental exam 12/24/2023
• Surgeries: No surgeries in the past
• Hospitalizations: No hospitalizations in the past
Allergies:
• No known allergies to medications
• No known allergies to food
• No allergies to latex
• No environmental allergies
Medications:
• Tylenol 650 PO every 6 hours as needed for pain. Last taking 3 days ago.
• No over the counter medication
• No vitamins or herbal products
Family History:
• Mother: 39 years old with no medical issues
• Father: 40 years old with no medical issues
• Sibling: younger sister with no medical issues
• Maternal Grandfather: hypertension, hyperlipidemia.
• Maternal Grandmother: No medical issues
• Paternal Grandfather: hypertension
• Paternal Grandmother: hypothyroidism, osteoporosis
Social History:
• Chemicals: Denies vaping or smoking or chewing tobacco. Denies exposure to secondhand smoke.
• Diet/exercise: Decrease appetite with nausea. Runs track and play football.
• Sexual History: Did not address as parents were in the exam room and no concern currently.
• Current living situation: Live in a house with parents and sister.
Review of Systems:
● Constitutional: (-) fatigue, (-) fever, (-) chills.
● Eyes: (-) blurry vision, (-) double vision, (-) light sensitivity.
● Ears: (-) sensitivity to noise (-) hearing loss
● Nose: (-) congestion
● Throat/neck: (-) throat pain, (-) pain/swelling of the neck
● Cardiovascular: (-) chest pain (-) palpitation
● Respiratory: (-) shortness of breath (-) cough.
● Neurologic: (-) headache, (-) dizziness, (-) slurred speech, (-) seizures, (-) gait disturbances.
● Gastrointestinal: (-) abdominal pain, (-) nausea, (-) diarrhea.
● Genitourinary: (-) incontinence, (-) flank pain, (-) urinary retention.
Objectives
Vital Signs:
• HR: 70. BP: 101/67 Temp: 98.0 F. RR: 16 SpO2: 100 Pain: 0/10
• Height: 5’ 11” Weight: 150 lb. BMI: 20.9 BMI Percentile: 55%
- Labs: None ordered today.
Physical Exam:
• General survey/constitutional: Patient with good hygiene, and in no acute distress. He is alert and oriented x4. He ambulated with steady gait without any difficulty. Patient is sitting at the exam table upright and using his cellphone.
• Head: round, normocephalic, atraumatic. No hematoma. No occipital tenderness elicited.
• Eyes: No eye drooping. No photosensitivity. Eyes PERRLA. Bilateral Pupils +3
• Ear: No visible deformity to bilateral ears. No redness, bulging, or rupture to Bilateral tympanic membranes.
• Nose: Nose is midline, without deformity. No redness or swelling to turbinate. Mucosa is pink, with no crust or exudates.
• Throat/Mouth/Neck: Tongue is midline with no deviation. No goiter.
• CV: S1/S2 present. No clicks, murmurs, gallops, or rubs auscultated.
• Pulmonary: No accessory muscle use. Clear lung sounds.
• Musculoskeletal: No deformities. No spinal step offs. Full range of motion present.
• Neuro: CN I-XII all intact. No numbness or tingling. Normal gait. No pronator drift. Negative Romberg test. Normal finger to nose test. Sensation and strength are grossly intact. Speech is normal. No slurred speech.
Cranial nerve I (olfactory): Patient denies loss of smell.
Cranial Nerve II (Optic): visual acuity 20/20 uncorrected to right, left, and bilateral eyes.
Cranial Nerve III (Oculomotor) Pupils constrict to direct light and consensually from 5mm to 3mm.
Cranial Nerve III, IV, VI (Oculomotor, Trochlear, and Abducens): 6 cardinals gaze were all normal with no nystagmus. No gaze deviation noted.
Cranial Nerve V (Trigeminal): sensation intact and equal to bilateral sides of face.
Cranial Nerve VII (Facial): No facial or eye drooping. Symmetrical smile. Symmetrical eyebrows when asked to raise them.
Cranial Nerve VIII (Vestibulocochlear): Intact hearing.
Cranial Nerve IX, X (Glossopharyngeal & Vagus): uvula rises when patient say “Ahh”, swallow without difficulty.
Cranial Nerve XI (Spinal Accessory): shoulder shrug bilaterally against resistance without weakness. Turn neck against resistance to right and left without difficulty or pain.
Cranial Nerve (Hypoglossal): Tongue is midline with no deviation. Able to move tongue side to side.
• Allergic/Immunologic: No allergies, no fevers, or hives.
Assessment
Diagnosis:
- Concussion without loss of consciousness, subsequent encounter (S06.0X0D): Plan
Diagnostic Plan:
• No imaging needed since patient symptoms resolved.
Therapeutic Plan:
• No medication prescribed at this encounter.
Referrals: None currently.
Education and Follow-up Plan:
• Patients can return to school as tolerated
• Patient can return to sport as tolerated
• Patient and parents to seek emergency medical care if patient develop slurred speech, increase confusion, and or seizure activity.
• Patient to follow-up PRN.
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