SOAP Note: Concussion
Subjective:
CC: “I tripped and hit my head while playing soccer.”
HPI: a 14-year-old male and his mother brought him into the clinic after receiving a call from the school nurse after having headaches and difficulty concentrating in class. He was playing soccer at the local playground the previous evening and was tripped by an opponent, he fell and hit his head hard on the soccer field—no loss of consciousness. The patient remembers falling and his teammate giving a helping hand to get up. The patient forgot to inform the mother of the incident. This morning about 30 minutes ago, he was seen at the RNs office, making a complaint about his difficulty concentrating in class, headache (7/10), and vomiting ×2. No Nausea? Vomiting since. No seizure. Now headache still (7/10). Light makes it more severe. The mother explains the patient has been acting normal, does not appear to be confused. The mother states that it is unusual for the patient to complain of headches.No prior history of headaches.Mother is concerned about the news in the media about kids with concussions, and the patient has a soccer game the next evening.
PMH: No chronic health conditions, no childhood diseases, no surgeries, or overnight hospitalizations.
FH: No significant history of neurologic diseases in the family, sudden death under the age of 50 or even stroke
SH: Lives in a single-family with a mother and an 18-year-old brother. No pets. Self-proclaimed as a strong and good athlete. Active in the soccer team and plays currently in the soccer season. He also plays basketball. He is doing well in school sand null developmental delays reported by the mother. The mother works at Sales in an insurance company—no smokers or drinkers at home.
Allergies: Mild seasonal allergies in winter-nasal congestion and cough.
Medications: Zyrtec in winter for allergies (Currently not intaking)
Immunizations: Needs flu shot for the season otherwise up to date.
ROS:
HEENT: Positive for a lump in the occipital area, photophobia, ringing in ears bilaterally. Negative for visual changes or phonophobia.
Neuro: Positive for difficulty with focus. Feels “foggy.” No dizziness, no difficulty with walking or balance. No history of neuro symptoms before yesterday’s fall. No seizures.
GI: Positive for nausea and vomiting x2 30 minutes ago. No nausea now.
Psych: No history of anxiety, depression or sleep disorders
Objective:
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 the exam table, gait is smooth and even. Speech is appropriate and smooth—no history of developmental delays or disorders.
Skin: Warm, dry, no rashes
Ecchymosis visible on the scalp over hematoma. +tenderness. No facial bruising or Battle’s sign.
Ears: Clean canals bilaterally, TMs visualized, +light reflex, no erythema, or edema bilaterally.
Eyes: PERRLA, +direct, and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. No strabismus, no nystagmus. Fundoscopic exam normal, vessels intact, an optic disc with clear margins. Nares patent with no edema or erythema. Uvula midline, palate rises symmetrically—tongue midline with no fasciculations.
Neck: Full ROM of the neck, no tenderness. No thyromegaly, no cervical lymphadenopathy
CV: RRR, S1, and S2 present. No murmurs, clicks, or gallops
Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi or rales
Abdomen: Soft, non-tender, non distended. Bowel sounds present in all four quadrants, no hepatosplenomegaly.
Romberg test negative, rapid alternating movement test negative. Tandem gait test negative, pronator drift negative. Whisper test negative. MMSE total 26 (Orientation to time 4/5, orientation to place 4/5, immediate word recall 2/3, serial sevens 4/5, delayed word recall 2/3, language 2/3, repetition of phrase 1/1, 3-part command 6/6)
Musculoskeletal: 5/5 strength and ROM in all extremities
Diagnostics: Not indicated
Assessment: Concussion, without loss of consciousness
Differential diagnoses:
Intracranial hematoma
Migraine
Tension headache
Cluster headache
Brain tumor
Plan:
Pain control: Tylenol 500mg every 5-6 hours
Brain rest: Low stimulation environment-no television, videogames.
Return to sports: Gradual return to play, the patient must stay 24 hours symptom-free for hi, to proceed to the next step. He won’t play soccer tomorrow.
Return precautions: The headaches are worse, change in behavior of the patient, repetitive vomiting, confusion, and weakness.
Clinical reasoning
Ask the patient how he got the injury, the location, and the type of force when the head received the blow-different biomechanics can cause different symptoms.
Ask if memory loss occurred-few seconds of memory loss may depict serious injury.
After checking general history use ACE form to access concussion symptoms and risk factors for serious injury
Children and teenagers are at higher risk for mild traumatic brain injuries. Younger children may also sustain mild, severe TBI from abuse.
Diagnostics
Perfuming imaging studies should be evaluated based on individual injury characteristics and weighing the risks and benefits associated with the test.
CT scan to identify hemorrhage or skull fracture 24-28 hours after the injury occurred.
Plan:
Complete the ACE return to sports form
Necessary to discuss safety? Prevention and education to wear properly treaded shoes to avoid tripping easily or protective gear wherever playing sports. An individual cannot return to play sports if they have any symptom associated with traumatic brain injury.
References
Covassin, T., Elbin, R. J., & Sarmiento, K. (2012). Educating coaches about concussion in
sports: evaluation of the CDC’s “Heads Up: Concussion in Youth Sports” initiative. Journal
of school health, 82(5), 233-238.
Chapter 5: SOAP Notes: The subjective and objective portion only
Giza, C. C., Kutcher, J. S., Ashwal, S., Barth, J., Getchius, T. S., Gioia, G. A., … & McKeag, D.
- (2013). Summary of evidence-based guideline update: evaluation and management of
concussion in sports: report of the Guideline Development Subcommittee of the American
Academy of Neurology. Neurology, 80(24), 2250-2257.
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9)