Post Concussion Syndrome Notes

Initial Assessment

  • Patient: 25-year-old male, football player
  • Injury: One week ago
  • Initial Presentation: Emergency Department, normal brain scan, discharged after observation.
  • Task: History taking, assessment of traumatic event, explanation of possible cause and diagnosis.

Positive Findings

  • Headache
  • Depressed mood
  • Sleep disturbances
  • Lack of energy
  • Decreased concentration
  • Feeling slowed down
  • Symptoms triggered after traumatic injury

History Taking - Open-Ended Questions

  • "Are you still having headaches?"
  • Express empathy and assure confidentiality.
  • "How are you feeling now?"
  • Describe the incident.

Incident Details

  • "What exactly happened?"
  • "Was it a direct blow?"
  • "Did you fall?"
  • "Did you land on your neck or your head?"

Red Flags

  • Level of consciousness?
  • Vomiting?
  • Blurring of vision?
  • Speech problems?
  • Neurological deficits (weakness or numbness)?

Post-Concussion Syndrome Symptoms - Detailed Questions

  • Headaches:
    • "Did you have any headaches?"
    • "Can you tell me the side of your headaches?"
    • Intensity?
    • Quality of pain?
    • What makes it better or worse?
  • Dizziness:
    • "Do you have any dizziness?"
    • Describe the dizziness:
      • Lightheadedness?
      • Spinning Sensation?
  • Energy Levels:
    • "Are you feeling tired?"
    • "Low in energy?"
  • Memory Problems:
    • "Do you have memory problems?"
  • Concentration Problems:
    • "Do you have concentration problems?"
  • Noise Sensitivity:
    • "Are you noise sensitive?"

Psychosocial History

  • Mood:
    • "How's your mood been?"
  • Sleep:
    • "How's your sleep?"
  • Appetite:
    • "How's your appetite?"
  • Suicidal/Homicidal Thoughts:
    • "Do you have any thoughts of harming yourself or anyone else?"
  • Support System:
    • "How do you live with?"
    • "Do you have enough support at home?"
  • Stressors:
    • "Do you have any stresses?"
  • Occupation:
    • "Do you work or study?"
  • Enjoyment:
    • "Do you still enjoy the things you used to enjoy?"
  • Nightmares/Flashbacks:
    • "Any nightmares?"
    • "Any flashbacks?"
  • Avoidance:
    • "Are you avoiding going back to football?"
  • Anger:
    • "Any recent anger outbursts?"

Medical and Family History

  • "Do you have any other medical history I should know about?"
  • "Any family history I should know about?"

Diagnosis

  • Most likely Post-Concussion Syndrome.
  • Symptoms of head injury lasting longer than expected.

Justification for Diagnosis

  • Headaches
  • Dizziness
  • Low mood
  • Tiredness and low energy
  • Brain injury and bleeding ruled out

Prognosis

  • Very good; most people get better in a few weeks.
  • Symptoms will improve.