Concussion Recovery Progress Note

Reason for Visit: - Patient presents for a follow-up visit to assess progress in concussion recovery, reporting ongoing visual symptoms. Visual History: - Patient reports intermittent blurriness, especially when reading, and occasional headaches after prolonged visual tasks. - Symptoms began approximately two weeks ago, following a sports-related concussion. The blurriness and headaches have fluctuated in intensity, with some days being better than others. - Patient has worn glasses for myopia since age 10. Current prescription is -2.50 in both eyes. Glasses have provided clear vision until the onset of concussion symptoms. Medical History: - No relevant chronic medical conditions. - Currently taking ibuprofen as needed for headaches. - No known allergies. Progress Since Last Encounter: - Patient reports a slight improvement in visual clarity and a reduction in headache frequency since the last visit. Lifestyle Assessment: - Patient is a student and spends several hours daily reading and using digital devices for schoolwork. - Patient uses digital screens for several hours a day. - Patient is not exposed to any environmental factors. Today's Therapy Session and Results of Binocular Vision and Eye Movement Programs: - Patient tolerated the therapy session well, with only mild reports of eye strain towards the end of the session. - Patient demonstrated improved eye tracking and convergence abilities during the therapy exercises. Other Relevant Issues: - No comments from other providers. - No changes to medications. - No new injuries or symptoms since last visit. Assessment: - Post-concussion visual syndrome. Management Plan: - Continue current glasses prescription. - Continue binocular vision therapy exercises at home and in-office. - Follow-up appointment scheduled in 4 weeks. - Patient was advised to take frequent breaks when using digital devices. - Patient was advised to return sooner if symptoms worsen. - Next appointment scheduled for 1 December 2024. Patient Education: - Patient was advised to take frequent breaks when using digital devices. - Patient was advised to return sooner if symptoms worsen. - Patient was instructed on proper eye hygiene and the importance of regular breaks. Any Additional Recommendations: - Patient was advised to take frequent breaks when using digital devices. - Patient was advised to return sooner if symptoms worsen.