Concussion PCS Initial Exam Form

Patient Name*

First NameLast Name

Date Of Injury*

Date

Today's Date*

Date

Vitals:

Height:   Height in inches*

Weight:   Weight in lbs*

Orthostatic Intolerance:

Supine (2 Min):
BP    Type a label*      /   Type a label*       Heart Rate:   Type a label*

Stand (2 Min):
BP   Type a label*    /     Type a label*        Heart Rate:   Type a label*

Mechanism of Injury: *

Direct Head Trauma*

YesNo

Loss of Consciousness:
Yes No*

Estimated Time *

Amnesia:

Retrograde: Yes No Type a label

Anterograde: Yes No Type a label

Current Symptoms:

Symptom Severity Score: Type a label /132

# Symptoms Present: Type a label /22

Exertion:

Physical Activity: Symptoms Worsen*

YesNo

Cognitive Activity: Symptoms Worsen*

YesNo

RED FLAGS:

Report / Evidence of Slurred Speech*

YesNo

Severe / Worsening HA*

YesNo

Can't Recognize People*

YesNo

Decreasing Consciousness*

YesNo

Seizures*

YesNo

Increasing Confusion / Irritability*

YesNo

Increasing Drowsiness*

YesNo

Signs of Skull Fracture*

YesNo

Vomiting x 2 Since Injury*

YesNo

Unusual Behavior Change*

YesNo

GCS < 15*

YesNo

Concussion History*

YesNo

If History of Concussion, please explain:

MEDICATIONS:

Anticoagulants:*

YesNo

Antiplatelets:*

YesNo

COMPLICATING FACTORS:

Behavioral Disorder*

YesNo

History of Headaches*

YesNo

If History of Headaches, please explain (type of headache, how long, migrane, etc.)

History of Anxiety:*

YesNo

History of Depression*

YesNo

History of Sleep Disorder*

YesNo

History of Mental DX*

YesNo

Observation Laceration / Contusion / Erythema*

YesNo

Speech Dysphagia (difficulty with speech): Dysphonia (unable to sustain tone/volume): Dysarthria (words not formed properly):*

YesNo

Notes On Clinical Observation

Mental Status Alert & Oriented x 4*

YesNo

Skull Fracture Signs Battle Sign / Racoon Eyes CSF (Otorrhea or Rhinorrhea) Hemotympanum*

YesNo

Palpation (Focal Tenderness)*

YesNo

Notes on Palpation

CRANIAL NERVES:

Olfactory*

NormalAbnormal

Optic Visual Acuity*

NormalChanged

Optic Confrontation:*

NormalAbnormal

Notes on Optic Confrontation

Cardinal Planes of Gaze (III, IV, and VI) Smooth Pursuits*

NormalAbnormalSaccades

Notes on Cardinal Planes of Gaze

Oculomotor: PERRL

Normal Abnormal*

Accommodation Right Accomodation Left Accomodation

Convergence NPC Convergence NPC

Oculomotor: PERRL Notes

Trigeminal*

NormalAbnormal

Facial*

NormalAbnormal

Vestibulocochlear (Hearing)*

NormalAbnormal

IX and X*

NormalAbnormal

Spinal Accessory*

NormalAbnormal

Hypoglossal*

NormalAbnormal

PYRAMIDAL TRACT

Pronator Drift*

NormalAbnormal

Hoffman’s*

PresentAbsent

CEREBELLAR

Finger-Nose*

NormalAbnormal

Finger-Finger*

NormalAbnormal

Romberg’s*

NormalAbnormal

Tandem Gait*

NormalAbnormal

Coordination*

NormalAbnormal

Rapid Alternating*

NormalAbnormal

Doctor’s Notes: *

Concussion W/O LOC (Initial Visit) S06.0X0A*

YesNo

Concussion W/ LOC < 30 Min (Initial Visit) S06.0X1A*

YesNo

Concussion W/ LOC Unspecified Duration (Initial Visit) S06.0X9A*

YesNo

Persistent Concussive Symptoms (PCS)AKA Post Concussion Syndrome F07.81*

YesNo

Convergence Insufficiency H51.11*

YesNo

Dizziness R42*

YesNo

BPPV H81.10*

YesNo

Any additional diagnoses?

Schedule:*

Prescribed:*

Concussion DietSleep Hygiene InstructionsAccommodation / Convergence Insufficiency

Notation: At 48 hours after the incident, I instructed the patient to increase resting heart rate 10 bpm for 15-20 minutes each day (then 15-20 bpm if tolerated). Patient instructed to discontinue the exercise if symptoms significantly worsen.

Yes, Noted

Psychological Complicating Factors Present*

YesNo

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*

99203 (New Patient; 30-44 Min)99204 (New Patient; 45-59 Min)99211 (Est Patient; Brief OV)99212 (Est Patient; 10-19 Min)99213 (Est Patient; 20-29 Min)99214 (Est Patient; 30-39 Min)99215 (Est Patient; 40-54 Min)97112 (Neuromuscular Re-education)

Doctors Notes:*

Provider Signature*

Date*

Date

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

Initial PCS Encounter

HISTORY

CLINICAL EXAMINATION

DIAGNOSES (ICD-10)

PLAN / RECOMMENDATIONS