SOAP NOTE: Concussion
Other good links to check out:
CC: “I fell and hit my hit while playing basketball.”
HPI: 13 year old male presents with mother, who brought him into clinic after receiving call from school nurse after having headaches and difficulty concentrating in class. He was playing basketball in his driveway last evening, and lost balance and fell hitting the back of his head on concrete. No loss of consciousness. Patient remembers hitting his head and friend giving him a hand to get up, forgot to tell mother. This morning (1 hour ago) he was seen at school RN’s office complaining of difficulty concentrating in class, headache (8/10) and vomiting x2. No nausea/vomiting since. No seizures. Now, headache is still 8/10. Light makes it worse. Mother states patient is acting normal, does not appear confused. Mother states that it is very unusual for patient to complain of headaches. No prior history of headaches. Mother is concerned because she has heard a lot in the media about kids with concussions and he has a basketball game scheduled tomorrow evening.
PMH: No chronic health conditions, no childhood diseases, no overnight hospitalizations or surgeries.
FH: No significant family history of neurologic diseases, sudden death under age 50, or stroke
SH: Lives in a single family home with mother and 17yo brother. No pets. Self described as “energetic and good at sports.” Active athlete currently in basketball season. Also plays baseball and football. Doing well in school, no developmental delays reported by mother.
Mother works in HR at a pharmaceutical company. No smokers at home.
Allergies: Mild seasonal allergies in spring – watery eyes, nasal congestion and cough
Meds: Zyrtec in spring season for allergies (not currently taking)
Immunizations: Needs flu shot for the season, but otherwise up to date.
VS: T 98.6F, RR 16, HR 72, BP 128/80 Ht 68 in Wt 132 lbs
General: Well nourished, well developed. Alert and oriented to time, place and person. Posture upright, intermittently rubs temples. Squinting. Friendly. Moves easily onto exam table, gait is smooth and even. Speech is appropriate and smooth. No history of developmental delays or disorders.
Diagnostics: Not indicated
Assessment: Concussion, without loss of consciousness
RTC in 2 days for evaluation of headache, or PRN if condition worsens
Ask the parent/child about how the injury occurred, type of force and location of the head when the blow was received – different biomechanics of injury can cause different symptoms.
Ask if memory loss (amnesia) occurred – even a few seconds of memory loss can predict serious injury.
After taking a general history, use the ACE form to assess concussion symptoms and risk factors for serious injury
Children and young adults (age 5-24 years) are at the highest risk for mild traumatic brain injuries (MBTI). Younger children may also sustain mild to severe TBI from abuse – important to consider possibility of abuse even in the absence of a history of trauma.
Performing imaging studies should be evaluated on the basis of individual injury characteristics, and weighing the risks/benefits of the test. Imaging studies are not needed in the vast majority of traumatic brain injuries.
The evidence-based decision tool for head injuries is the PECARN rule here:
This patient has normal mental status, no signs of basilar skull fracture, no severe mechanism of injury, no LOC, no severe headache or vomiting. He might be observed in the ED immediately following the event but no observation or imaging is needed for this stable patient the following day. Now, you are managing his concussion.
CT scans can identify hemorrhages or skull fractures 24-48 hours after injury.
MRI can be used 48 hours or more after injury to assess for worsening symptoms or slow intracranial bleeds
Complete the ACE Return to School/Sports form for a written action plan.
Important to discuss safety/prevention and provide education to wear properly fitted and secured helmets or protective gear whenever playing sports. An individual cannot return to playing sports when experiencing even the mildest or lingering symptoms of traumatic brain injury.
Photo used under Creative Commons from Jim Bahn