Concussion Initial Intake

Concussion Initial Intake Pre-injury Profile Prior to injury: Patient was a high-achieving student, actively involved in sports and social activities. Level of independence prior to accident: Independent in all activities of daily living. Past medical history (PMHx): No significant past medical history. Previous traumatic brain injury (TBI): Denies any previous TBI. History of seizures: Denies history of seizures. History of migraines/headaches: Occasional tension headaches, managed with over-the-counter medication. Medications prior to injury: None. Injury Description Patient’s account or external reports of the injury (e.g., X reports): Patient reports being hit in the head during a soccer game. Witness reports confirm a collision with another player. No loss of consciousness. Loss of consciousness: No loss of consciousness. Last memory before injury: Patient remembers playing in the soccer game. First memory after injury: Patient remembers feeling dazed and confused after the collision. Medical input / Emergency Department presentation: Presented to the Emergency Department immediately after the injury. CT scan of the head was performed, which was unremarkable. Discharged home with instructions for rest and observation. Other injuries sustained: No other injuries reported. Medications post-injury (e.g., analgesia): Paracetamol for headache management. Post-injury Profile Reported symptoms following injury: Patient reports headaches, dizziness, and difficulty concentrating. Physical Symptoms Neck complaints: Reports mild neck stiffness. Headaches: Reports headaches, primarily in the frontal region, rated 5/10 in severity. Coordination difficulties: Reports some clumsiness. Dizziness: Reports intermittent dizziness, especially with rapid head movements. Balance issues: Reports feeling unsteady on their feet. Mobility status or impairments: No significant mobility impairments. Nausea/vomiting: Reports occasional nausea. Taste, smell, appetite, or diet changes: Appetite decreased. Sleep disturbances: Difficulty falling asleep and staying asleep. Fatigue: Reports significant fatigue. Noise sensitivity: Reports increased sensitivity to noise. Light sensitivity: Reports increased sensitivity to light. Vision impairments or changes: Reports blurry vision. Cognitive Symptoms Cognitive concerns: concentration, attention, thinking, information processing, memory: Difficulty concentrating in class, trouble remembering recent conversations, and feeling mentally foggy. Psychological Symptoms Mental health history: No prior history of mental health issues. Alcohol or illicit drug use: Denies alcohol or illicit drug use. Coping skills, involvement in legal or court proceedings: Patient is a student and has a supportive family. Mood changes: frustration, irritability, emotional lability, flat affect: Reports increased irritability and frustration. Life and Social Impact Current living arrangements: Lives at home with parents. Leisure activities, sports, and personal roles: Unable to participate in sports or social activities. Financial stressors: No financial stressors. Driving ability or restrictions: Not applicable. Work, school, or study impact: Unable to attend school. Medical certificate details: Medical certificate provided for school absence. Date: 1 November 2024