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
Pre-injury Profile
[Prior to injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Level of independence prior to accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Past medical history (PMHx)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Previous traumatic brain injury (TBI)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[History of seizures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[History of migraines/headaches] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Medications prior to injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Injury Description
[Patient’s account or external reports of the injury (e.g., X reports)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Loss of consciousness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Last memory before injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[First memory after injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Medical input / Emergency Department presentation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Other injuries sustained] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Medications post-injury (e.g., analgesia)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Post-injury Profile
[Reported symptoms following injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physical Symptoms
[Neck complaints] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Headaches] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Coordination difficulties] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Dizziness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Balance issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Mobility status or impairments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Nausea/vomiting] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Taste, smell, appetite, or diet changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Sleep disturbances] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Fatigue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Noise sensitivity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Light sensitivity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Vision impairments or changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Cognitive Symptoms
[Cognitive concerns: concentration, attention, thinking, information processing, memory] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Psychological Symptoms
[Mental health history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Alcohol or illicit drug use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Coping skills, involvement in legal or court proceedings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Mood changes: frustration, irritability, emotional lability, flat affect] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Life and Social Impact
[Current living arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Leisure activities, sports, and personal roles] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Financial stressors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Driving ability or restrictions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Work, school, or study impact] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Medical certificate details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
