Concussion Initial Acute Exam Form

Initial Acute Concussion Encounter
Patient Name*

First NameLast Name
Date Of Injury*

MonthDayYear
Date
Today's Date*

MonthDayYear
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*
HISTORY
Mechanism of Injury: *
Direct Head Trauma*

YesNo
Loss of Consciousness:*

YesNo
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
GCS < 15*

YesNo
Concussion History*

YesNo
MEDICATIONS:
Anticoagulants:*

YesNo
Anticoagulants:*

YesNo
COMPLICATING FACTORS:
Behavioral Disorder*

YesNo
History of Headaches*

YesNo
History of Anxiety:*

YesNo
History of Depression*

YesNo
History of Sleep Disorder*

YesNo
History of Mental DX*

YesNo
CLINICAL EXAMINATION
Observation Laceration / Contusion / Erythema*

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

YesNo
Mental Status Alert & Oriented x 4*

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

YesNo
Palpation (Focal Tenderness)*

YesNo
CRANIAL NERVES:
Olfactory*

NormalAbnormal
Optic Visual Acuity*

NormalChanged
Optic Confrontation:*

NormalAbnormal
Oculomotor: PERRL

Normal   Abnormal

Accommodation   Right:Type a label   Left   Type a label

Convergence NPC   Type a label
Cardinal Planes of Gaze (III, IV, and VI) Smooth Pursuits*

NormalAbnormalSaccades
Trigeminal*

NormalAbnormal
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: *
DIAGNOSES (ICD-10)
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?
PLAN / RECOMMENDATIONS
Schedule:*

Neurocognitive Testing / Neurologic Co-ManagePhysiologic Testing (BCTT / BCBT)Vestibulo-Ocular EvalCervicogenic EvalBESS Testing
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*

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*

Clear
Date*

MonthDayYear
Date
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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Initial Acute Concussion Encounter

HISTORY

CLINICAL EXAMINATION

DIAGNOSES (ICD-10)

PLAN / RECOMMENDATIONS