Provide a SOAP note for a 17‑year‑old male with a concussion from a football injury 5 days ago, brief loss of consciousness, and ongoing headaches and a dazed (cognitive fog) sensation.

SOAP Note for 17-Year-Old with Concussion

SUBJECTIVE

Chief Complaint: Persistent headaches and feeling "in a daze" 5 days after football-related head injury

History of Present Illness:

• Mechanism of injury: Direct impact while playing football 5 days ago
• Loss of consciousness: Brief ("split second") LOC at time of injury
• Current symptoms:
  • Ongoing headaches
  • Cognitive fog/feeling "dazed" (suggests cognitive-emotional symptoms)
  • Duration: 5 days post-injury with no resolution

Pertinent Negatives to Assess:

• Worsening headache, repeated vomiting, seizures, visual changes, focal neurological deficits (red flags requiring emergency evaluation) 1, 2
• Amnesia (retrograde or anterograde)
• Confusion at time of injury
• Balance problems, dizziness, neck pain
• Sleep disturbances
• Emotional changes (irritability, sadness, anxiety)
• Sensitivity to light or noise
• Difficulty concentrating in school

Return to Activity Status:

• Confirm complete removal from football since injury 1, 2
• Current activity level (physical and cognitive)
• School attendance and performance

Past Medical History:

• Previous concussions (critical prognostic factor) 3
• Baseline headache or migraine history
• Mental health history
• Learning disabilities

OBJECTIVE

Vital Signs: Document and ensure stable

General Appearance: Alert, appears stated age, in no acute distress vs. appears fatigued/confused

Neurological Examination:

• Mental Status: Orientation to person, place, time, situation; attention span; memory (immediate, short-term)
• Cranial Nerves: Pupils equal, round, reactive to light; extraocular movements intact vs. impaired; visual fields; facial symmetry
• Motor: Strength 5/5 all extremities, tone normal, no drift
• Sensory: Intact to light touch
• Reflexes: 2+ and symmetric throughout
• Coordination: Finger-to-nose, heel-to-shin testing
• Gait: Observe for ataxia, tandem gait assessment
• Balance: Romberg test, single-leg stance

Vestibular/Oculomotor Assessment:

• Smooth pursuits, saccades
• Vestibulo-ocular reflex testing
• Near-point convergence

Cognitive Screening:

• Concentration (digit span backwards, months in reverse)
• Memory (word list recall)
• Processing speed

Cervical Spine: Range of motion, tenderness, muscle spasm

Head/Scalp: Inspect for contusions, lacerations, hematomas, deformities

ASSESSMENT

Primary Diagnosis: Sport-related concussion with persistent symptoms (Day 5 post-injury)

Clinical Reasoning: This 17-year-old athlete has a confirmed concussion based on mechanism of injury, brief LOC, and ongoing post-concussive symptoms beyond the typical 24-72 hour acute phase. 4, 5 The persistence of headaches and cognitive fog at 5 days indicates he is not following the typical rapid recovery trajectory seen in most adolescents (who recover within 7-10 days) 6.

Key Clinical Considerations:

• Brief LOC is a documented risk factor but does not necessarily predict prolonged recovery 7
• Symptom profile suggests possible migraine-type cluster (headache predominant) or cognitive-emotional cluster (dazed/foggy) 8
• At Day 5, he remains symptomatic and therefore absolutely cannot return to contact sports 1, 2, 1, 6, 2
• No imaging is indicated unless red flags develop (worsening symptoms, focal deficits, repeated vomiting, altered consciousness) 1, 9

Risk Stratification:

• History of previous concussions would significantly worsen prognosis 3
• Adolescents typically require 7-10+ days for cognitive recovery 6
• Symptoms persisting beyond 10 days may benefit from targeted rehabilitation 5

PLAN

1. Immediate Activity Restrictions

Physical Rest:

• Complete removal from all football activities (practice, games, contact drills) 1, 2, 1, 6, 2
• Avoid high-intensity physical activity that exacerbates symptoms 4, 6
• Begin light aerobic activity (walking, stationary cycling) at sub-symptom threshold if tolerated 4, 5
  • This is evidence-based for adolescents and superior to strict rest 4, 5
  • Activity should not worsen symptoms; if symptoms increase, reduce intensity

Cognitive Rest:

• School modifications are mandatory 6, 9:
  • Shortened school day if full day worsens symptoms
  • Extended time for assignments and tests
  • Reduced workload, especially in math, science, foreign languages
  • No standardized testing until fully recovered 6
  • Breaks during class as needed
  • Preferential seating away from bright lights/noise
• Limit screen time (phones, computers, video games, TV) 6, 5
• Avoid loud music, headphones if phonophobia present 6
• Consider temporary driving restrictions due to slowed reaction time 6

2. Symptom Management

Headache:

• NSAIDs (ibuprofen 400-600mg q6-8h PRN or acetaminophen 500-1000mg q6h PRN)
• Avoid opioids
• Dark, quiet environment
• Adequate hydration
• If headaches persist >10 days, consider cervical/vestibular component 5

Cognitive Fog:

• Reassurance that this is expected and temporary
• Cognitive rest as above
• Gradual reintroduction of cognitive activities as tolerated

3. Return-to-Activity Protocol

The athlete MUST be completely asymptomatic at rest before beginning graduated return-to-play 1, 6. This is non-negotiable.

Stepwise Progression (minimum 24 hours per stage): 1, 6

1. Stage 1: Complete physical and cognitive rest until asymptomatic
2. Stage 2: Light aerobic exercise (walking, stationary cycling at <70% max HR, no resistance training)
3. Stage 3: Sport-specific exercise (football drills, running, NO head contact)
4. Stage 4: Non-contact training drills (more complex drills, may add light resistance training)
5. Stage 5: Full-contact practice (requires medical clearance)
6. Stage 6: Return to game play

Critical Rules:

• If ANY symptoms return at any stage, drop back to previous asymptomatic level for 24 hours 1, 6
• Minimum 5 days to complete protocol (realistically 7-10+ days for adolescents) 6
• "When in doubt, sit them out" 1

4. Return-to-School Protocol

Parallel to return-to-play but prioritized first 5, 9:

• Begin with partial school days
• Gradually increase cognitive load
• Full school day without symptoms before advancing to Stage 3 of return-to-play
• Coordinate with school nurse, teachers, counselors 6, 9

5. Monitoring and Follow-Up

Follow-up in 3-5 days (Day 8-10 post-injury):

• Reassess symptoms using standardized scale
• If symptoms persist >10 days: Consider referral for specialized concussion care 5
  • Cervicovestibular rehabilitation if dizziness/neck pain/headache predominant 5
  • Active rehabilitation and collaborative care if symptoms persist >30 days 4, 5

Red Flag Education - Return to ED immediately if: 1, 2, 9

• Worsening or severe headache
• Repeated vomiting
• Seizure activity
• Increasing confusion or altered mental status
• Visual changes
• Focal weakness or numbness
• Loss of consciousness
• Neck pain with neurological symptoms

6. Neuropsychological Testing

• Consider computerized testing (ImPACT, CogSport) if available, though not required for diagnosis 1, 7
• More useful for return-to-play decisions in complex cases
• Athletes with testing are less likely to return prematurely 7

7. Imaging

• NOT indicated at this time 1, 9, 10
• CT/MRI only if red flags develop suggesting structural injury 1, 9

8. Education and Counseling

Patient and Family Education:

• Natural history: Most adolescents recover in 7-10 days, some take longer 6
• Absolute prohibition from contact sports while symptomatic 1, 2, 1, 6, 2
• Risk of second impact syndrome if returns prematurely (rare but catastrophic)
• Importance of reporting symptom recurrence during graduated protocol
• Expected timeline and need for patience

Documentation:

• Provide written return-to-play protocol
• School accommodation letter
• Emergency precautions handout

9. Prognosis Discussion

• Most adolescents recover fully within 2-4 weeks 6, 5
• Small percentage (1.5%) have symptoms >1 month 7
• If previous concussions exist, recovery may be prolonged 3
• Emphasize that full recovery is expected with appropriate management

---

Common Pitfalls to Avoid:

• Never allow same-day return to play - this is explicitly contraindicated in adolescents 6, 2
• Do not prescribe strict rest beyond initial 24-48 hours - evidence shows this is detrimental 4, 5
• Do not order imaging routinely - it does not aid in concussion diagnosis and exposes to unnecessary radiation 1, 9, 10
• Do not allow return to contact before return to school - cognitive recovery precedes physical recovery 5, 9
• Do not underestimate school impact - teachers often don't recognize cognitive impairment because athlete "looks fine" 6