What is the recommended assessment and management for a patient with a concussion that occurred a day ago in a primary care setting?

Concussion Assessment in Primary Care (Day 1 Post-Injury)

For a patient presenting one day after concussion, perform a structured clinical assessment including symptom evaluation, cognitive testing, balance assessment, and neurological examination, followed by initiation of 24-48 hours of complete rest with clear instructions for monitoring and return precautions. 1

Immediate Assessment Components

Symptom Evaluation

• Use a standardized graded symptom checklist to document all present symptoms and their severity, including headache, dizziness, nausea, balance problems, sensitivity to light/noise, feeling mentally foggy, difficulty concentrating, memory problems, irritability, and sleep disturbance 1, 2
• Assess for five concussion subtypes: cognitive, vestibular, ocular, headache/migraine, and anxiety/mood, as these commonly manifest within the first 3 days 1

Cognitive Assessment

• Perform brief cognitive testing including orientation, immediate and delayed memory, new learning, and concentration 1, 2
• The Standardized Assessment of Concussion (SAC) is validated for this purpose and shows little practice effect 3

Balance Testing

• Conduct Balance Error Scoring System (BESS) or similar balance assessment 1, 2
• Note that balance testing in the office may differ from baseline due to footwear and surface differences 2

Neurological Examination

• Perform cranial nerve examination with emphasis on oculomotor and vestibular systems 4, 5
• Assess cervical spine range of motion, tenderness, and perform Spurling maneuver 5
• Test deep tendon reflexes and manual muscle strength 5
• Evaluate gait and coordination 3

Critical Red Flags Requiring Neuroimaging

Order CT imaging if any of the following are present: 3

• Glasgow Coma Scale score <15 at 2 hours post-injury
• Suspected open or depressed skull fracture
• Worsening headache
• Repeated vomiting
• Irritability on examination
• Any signs of deteriorating mental status

CT is the imaging modality of choice within the first 24-48 hours to evaluate for intracranial hemorrhage or skull fracture 3. Routine imaging is not indicated for uncomplicated concussion with normal examination 3, 1.

Initial Management (Days 1-2)

Rest Protocol

• Prescribe complete physical and cognitive rest for 24-48 hours 1
• Cognitive rest includes limiting screen time, reading, texting, video games, and schoolwork 1, 2
• Avoid all physical exertion during this initial period 1

Medication Guidance

• Acetaminophen is acceptable for headache management 1
• Avoid NSAIDs in the acute period due to theoretical bleeding risk 1
• Do not prescribe medications to mask symptoms for return-to-activity purposes 3

Monitoring Instructions

• Provide clear written instructions on warning signs requiring emergency evaluation: severe or worsening headache, repeated vomiting, seizures, increasing confusion, weakness/numbness, slurred speech, or inability to wake 3
• Symptoms may worsen or new symptoms may appear in the first 24-48 hours 1

Academic Accommodations

Students require cognitive rest and academic modifications: 1, 2

• Reduced workload and extended time for tests
• Frequent breaks during the school day
• Delayed return to full academic schedule
• Temporary exemption from standardized testing if symptomatic

Follow-Up Planning

Timing of Reassessment

• Schedule follow-up within 3-7 days to reassess symptoms and plan return-to-activity progression 1
• More frequent monitoring may be needed for patients with severe initial symptoms or concerning features 1

Criteria for Specialist Referral

Refer to concussion specialist or multidisciplinary team if: 1, 4

• Symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents
• Symptoms worsen despite appropriate rest
• History of multiple prior concussions
• Pre-existing mood disorders, learning disabilities, ADHD, or migraines complicating recovery
• Athlete requires clearance for return-to-sport

Special Considerations for High-Risk Patients

Youth Athletes (<18 years)

• Manage more conservatively with stricter return-to-play guidelines 1
• Recovery takes longer in adolescents 1
• Risk of catastrophic second-impact syndrome, though rare, is highest in this age group 1

History of Prior Concussions

• These patients have increased risk of subsequent injuries, slower recovery, and prolonged cognitive dysfunction 1
• Lower threshold for specialist referral and more conservative management 1

Return-to-Activity Protocol (Not Started Until Asymptomatic)

Do not initiate return-to-activity progression until the patient is completely symptom-free at rest: 1, 2

The stepwise protocol includes: 1

1. Complete rest (24-48 hours minimum)
2. Light aerobic exercise (walking, stationary bike)
3. Sport-specific training (no contact)
4. Non-contact training drills
5. Full contact practice (with medical clearance)
6. Return to game play

Each step requires minimum 24 hours, and if symptoms recur at any stage, return to the previous symptom-free step 3, 1. No return to play should occur on the day of injury under any circumstances 3, 1, 2.

Documentation

• Record all findings using standardized forms 1
• Document time of injury, mechanism, immediate symptoms, and serial assessment findings 1
• Baseline documentation is critical for tracking recovery trajectory 1