S (Subjective) Patient is a 32-year-old right-hand dominant male who presents with a laceration to his right index finger sustained approximately 2 hours ago while cutting vegetables with a kitchen knife. Wound was washed at home with soap and water. No longer actively bleeding. Reports mild pain (4/10) at the wound site. Denies numbness or tingling distal to the wound. Denies loss of range of motion. Tetanus immunization current (received 3 years ago). No known drug allergies. No blood thinners or immunosuppressants.

O (Objective)

• Vital Signs:

  • BP: 126/80 mmHg
  • HR: 78 bpm
  • Temp: 37.1°C

• Wound Exam (pre-repair):

  • Location: Volar aspect, right index finger, mid-distal phalanx
  • Length: 2.5 cm
  • Depth: Full-thickness dermis; no tendon, joint capsule, or bone involvement
  • Edges: Clean, well-approximated passively; no foreign body on visual inspection
  • Contamination: Minimal; clean kitchen environment
  • Bleeding: Controlled with direct pressure; no arterial bleeding

• Neurovascular Exam (pre-repair):

  • Sensation: Intact to light touch radial and ulnar digital nerves distal to wound
  • Motor: Full range of motion at DIP and PIP joints; grip strength normal
  • Capillary refill: < 2 seconds at fingertip

• Procedure:

  • Wound irrigated with 150 mL NS via syringe and 18-gauge angiocath
  • Digital block: 3 mL 1% lidocaine without epinephrine — radial and ulnar digital nerves at base of finger
  • Wound edges debrided minimally; no foreign material identified
  • Wound closed with 4-0 nylon simple interrupted sutures x 5
  • Wound approximated well; hemostasis achieved
  • Dressing: Non-adherent gauze, padded dressing applied

• Neurovascular Exam (post-repair): Sensation intact; full ROM preserved; capillary refill < 2 seconds

A (Assessment)

1. S61.210A — Laceration without foreign body of right index finger, initial encounter
2. Wound repair performed: simple repair of 2.5 cm, right index finger

P (Plan)

1. Wound care: Keep wound clean and dry x 24 hours; then clean with mild soap and water daily; apply petroleum jelly and non-adherent dressing; change dressing daily
2. Suture removal: Return to urgent care or primary care in 7–10 days for suture removal (finger wounds typically 7–10 days)
3. Activity restrictions: Avoid soaking wound or submersion (no swimming or dishwashing) until sutures removed; light use of hand permitted
4. Antibiotics: None indicated (clean laceration, < 12 hours old)
5. Pain management: Acetaminophen 500–1000 mg PO q6h PRN; ibuprofen 400–600 mg PO q6h PRN with food
6. Return precautions: Return immediately if signs of infection develop: increasing redness, warmth, purulent discharge, fever, or worsening pain; also return if numbness, tingling, or inability to move finger develops
7. Patient education: Reviewed wound care instructions verbally and with written handout; patient verbalized understanding

S (Subjective) Patient is a 22-year-old female who inverted her right ankle while playing recreational basketball approximately 2 hours ago. She heard a "pop" at the time of injury. Reports immediate lateral ankle pain (7/10) and swelling. Was able to ambulate off the court with assistance. Denies any prior ankle injuries on the right. Denies numbness or tingling. No prior ankle surgery. Takes no prescription medications. No known drug allergies.

O (Objective)

• Vital Signs:

  • BP: 118/74 mmHg
  • HR: 88 bpm
  • Temp: 37.0°C

• Musculoskeletal Exam — Right Ankle:

  • Inspection: Moderate lateral ankle swelling and ecchymosis; no gross deformity
  • Palpation: Tenderness over anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL); no tenderness at posterior tip of fibula or medial malleolus; no tenderness at base of 5th metatarsal or navicular
  • ROM: Dorsiflexion and plantarflexion limited by pain; inversion limited and painful; eversion mildly limited
  • Anterior Drawer Test: Grade I laxity; slight increased translation vs. contralateral (no frank instability)
  • Talar Tilt Test: No significant increase vs. contralateral side
  • Neurovascular: Sensation intact; capillary refill < 2 seconds; DP and PT pulses 2+ bilaterally

• Ottawa Ankle Rules Applied: Negative (no tenderness at posterior edge or tip of medial/lateral malleolus; able to bear weight x 4 steps in office); X-ray not indicated

• Functional Assessment: Able to bear weight with limp; gait antalgic favoring lateral side

A (Assessment)

1. S93.401A — Sprain of right ankle, unspecified ligament, initial encounter (Grade I–II lateral ankle sprain — ATFL and CFL, clinically)

P (Plan)

1. PRICE therapy: Protect (soft ankle brace or ace wrap), Rest (avoid high-impact activity), Ice (20 min on/off q2h for 48 hours), Compression (ace wrap), Elevation (above heart level when resting)
2. Brace: Lace-up ankle stabilizer dispensed; reviewed proper application
3. Weight-bearing: Full weight-bearing as tolerated with brace; crutches offered but declined by patient
4. Medications: Ibuprofen 600 mg PO TID with food x 5 days; acetaminophen 500–1000 mg q6h PRN for breakthrough pain
5. Physical therapy: Recommended PT referral at 1-week follow-up if not significantly improved; begin early proprioceptive exercises (towel scrunches, alphabet tracing) once pain allows
6. Activity: No sports participation for minimum 2 weeks or until pain-free weight-bearing and functional ROM restored
7. Return precautions: Return if significant worsening, new numbness/tingling, inability to bear any weight, or bruising extending above ankle (concerning for high ankle sprain); obtain X-ray at that time
8. Follow-up: Primary care in 5–7 days for reassessment; sooner if worsening

S (Subjective) Patient is a 28-year-old female with 5 days of progressively worsening nasal congestion (thick yellow-green discharge), mild sore throat, and productive cough with yellow sputum. Reports mild fatigue. Temp at home: 37.4°C (no fever). Denies ear pain. Denies shortness of breath. Denies facial pain or pressure. Sick contact: toddler at home with URI symptoms for one week. No prior URIs requiring antibiotics. No known drug allergies. No immunosuppression. Does not smoke.

O (Objective)

• Vital Signs:

  • Temp: 37.2°C
  • BP: 118/76 mmHg
  • HR: 82 bpm
  • Resp: 16/min
  • SpO2: 99% on room air

• Physical Exam:

  • General: Alert, well-appearing; mild nasal voice; no acute distress
  • HEENT:
    • Nasal mucosa: Erythematous with mucopurulent secretions bilaterally; no nasal polyps
    • Sinuses: No maxillary or frontal sinus tenderness on palpation
    • TMs: Clear bilaterally; good light reflex; no effusion
    • Pharynx: Mild erythema; no exudate; no tonsillar enlargement; Centor score = 0 (no exudate, no tender anterior cervical LAN, no fever, no absence of cough)
    • Neck: No lymphadenopathy
  • Pulmonary: Clear to auscultation bilaterally; no wheeze; no rales

A (Assessment)

1. J06.9 — Acute upper respiratory infection, unspecified (viral rhinosinusitis — viral etiology most likely given duration ≤ 7 days, low Centor score, and viral URI in household contact)
2. Antibiotic therapy NOT indicated — counseled on appropriate antibiotic stewardship

P (Plan)

1. Antibiotics: Not indicated; viral etiology most likely. Explained SNAP criteria and antibiotic stewardship to patient; patient initially concerned but verbalized understanding and agreement.
2. Symptomatic treatment:
   • Pseudoephedrine 30 mg PO q4–6h PRN congestion (max 5 days; avoid in patients with hypertension)
   • Guaifenesin 600–1200 mg PO q12h PRN cough/congestion
   • Saline nasal rinse (Neti Pot or NeilMed) BID
   • Throat lozenges or warm saltwater gargle for throat discomfort
   • Acetaminophen 500–1000 mg q6h PRN aches or fever
3. Hydration: Increase fluid intake; rest
4. Return precautions: Return if fever develops (> 38.5°C), symptoms significantly worsen after initial improvement (may indicate secondary bacterial sinusitis or pneumonia), symptoms persist > 10 days without improvement, or facial pain/pressure develops
5. Follow-up: Not needed if symptoms resolve; follow up with primary care if not improved in 7–10 days

S (Subjective) Patient is a 35-year-old female with 3 days of burning with urination, increased urinary frequency (urinating every 1–2 hours), and urgency. Mild suprapubic discomfort. No fever at home. Denies flank or back pain. Denies nausea or vomiting. No vaginal discharge or odor. Not pregnant (last period 2 weeks ago; not sexually active currently). Prior UTIs x2 in the past 2 years — treated with TMP-SMX and ciprofloxacin respectively; both resolved. No known drug allergies. No recent antibiotic use.

O (Objective)

• Vital Signs:

  • Temp: 37.1°C
  • BP: 116/72 mmHg
  • HR: 80 bpm
  • Resp: 16/min

• Physical Exam:

  • General: Well-appearing; mild discomfort
  • Abdomen: Soft; mild suprapubic tenderness on palpation; no CVA tenderness bilaterally; no guarding or rebound
  • GU: Deferred given classic presentation; no vaginal symptoms reported

• Point-of-Care Urinalysis (clean-catch midstream):

  • Appearance: Cloudy, yellow
  • Leukocyte esterase: 3+
  • Nitrites: Positive
  • WBCs: 30–50/hpf
  • Bacteria: Moderate gram-negative rods
  • RBCs: 5–10/hpf (micro-hematuria, not uncommon in cystitis)
  • Protein: Trace

• Urine culture: Sent; results pending 48–72 hours

A (Assessment)

1. N39.0 — Urinary tract infection, site not specified (uncomplicated cystitis — no fever, no systemic symptoms, no CVA tenderness, afebrile)

P (Plan)

1. Antibiotics: Nitrofurantoin macrocrystal (Macrobid) 100 mg PO BID x 5 days (first-line for uncomplicated cystitis per IDSA guidelines; avoid if CrCl < 30)
2. Phenazopyridine: 200 mg PO TID x 2 days for symptomatic relief of dysuria; counseled that urine will turn orange
3. Hydration: Increase fluid intake; 8+ glasses water daily
4. Culture follow-up: Will call within 48 hours to confirm organism sensitivity; will switch antibiotics if organism resistant to nitrofurantoin
5. Recurrence discussion: Reviewed risk factors for recurrent UTI (post-void wiping technique, urinating before/after intercourse if sexually active, cotton underwear). Discussed test-of-cure urine culture in 5–7 days given recurrent history.
6. Return precautions: Return immediately if develops fever (> 38°C), chills/rigors, flank pain (suggesting pyelonephritis), or symptoms don't improve in 48–72 hours
7. Primary care follow-up: Refer to primary care physician for recurrent UTI evaluation if this is a 3rd episode in 12 months (consider prophylaxis discussion)

S (Subjective) Patient is a 45-year-old male with acute onset lower back pain that began yesterday while lifting a heavy box at work (estimated weight 60 lbs). Describes the pain as sharp and localized to the lower lumbar region. Pain rated 7/10. No radiation to buttocks or legs. Denies numbness, tingling, or weakness in either lower extremity. Denies bladder or bowel dysfunction. No prior history of back surgery. Prior mild low back pain episodes x2 in past 5 years — both resolved with NSAIDs and rest. No recent fever, weight loss, or night pain (no red flag symptoms). Ibuprofen 200 mg at home — minimal relief. No known drug allergies.

O (Objective)

• Vital Signs:

  • BP: 132/82 mmHg
  • HR: 84 bpm
  • Temp: 37.0°C

• Musculoskeletal Exam:

  • Inspection: No scoliosis; normal lumbar lordosis; no bruising or step-off
  • Palpation: Moderate tenderness over L3–L5 bilateral paraspinal musculature; no midline spinous process tenderness
  • ROM: Lumbar flexion limited to 30° by pain (normal 80–90°); extension limited to 5° by pain; lateral bending 10° bilaterally; rotation mildly limited
  • Gait: Antalgic; able to ambulate independently

• Neurological Screen:

  • Straight Leg Raise (SLR): Negative bilaterally (no radicular pain with passive hip flexion to 60°)
  • Strength: Hip flexors, knee extensors, ankle dorsiflexors and plantarflexors — 5/5 bilaterally
  • Sensation: Intact to light touch L3–S1 dermatomal distributions bilaterally
  • Reflexes: Patellar 2+ bilaterally; Achilles 2+ bilaterally

A (Assessment)

1. M54.50 — Low back pain, unspecified (acute musculoligamentous strain, no neurological involvement)
2. No red flags present (no fever, no weight loss, no bowel/bladder dysfunction, negative SLR, intact neurology)

P (Plan)

1. NSAIDs: Ibuprofen 600 mg PO TID x 5–7 days with food (adequate dose — patient was only taking 200 mg); Famotidine 20 mg daily for GI protection
2. Muscle relaxant: Cyclobenzaprine 5 mg PO TID PRN x 5 days (for significant muscle spasm; counsel regarding drowsiness — avoid driving); short-term use only
3. Activity: Encourage continued activity as tolerated; avoid bed rest; light walking encouraged. Return to work if sedentary; modified duty if lifting is required.
4. Heat/cold: Alternating ice (first 48 hours) and heat packs 20 minutes, several times daily
5. Imaging: No imaging indicated at this time (acute mechanical back pain < 6 weeks without red flags or neurological deficits — consistent with AHRQ/ACP guidelines)
6. Return precautions: Return immediately or go to ED if develops weakness in legs, loss of bladder or bowel control, severe or worsening neurological symptoms, or fever
7. Follow-up: Primary care in 1–2 weeks if not improved; most acute back strains resolve within 6 weeks; refer to physical therapy if not improving at 4 weeks

S (Subjective) Patient is a 19-year-old male who jammed his right ring finger while catching a basketball approximately 3 hours ago. Reports immediate pain (8/10), swelling, and difficulty moving the finger. Denies any open wound. Right-hand dominant. No prior injuries to this finger. No blood thinners. Tetanus current. No known drug allergies.

O (Objective)

• Vital Signs:

  • BP: 120/76 mmHg
  • HR: 82 bpm
  • Temp: 37.1°C

• Musculoskeletal Exam — Right Ring Finger:

  • Inspection: Moderate swelling and ecchymosis at the MCP/proximal phalanx; no gross deformity; no rotational malalignment with fingers passively flexed
  • Palpation: Maximal tenderness at the base of the proximal phalanx (lateral aspect)
  • ROM: Active flexion at PIP and DIP limited by pain; MCP ROM restricted; full extension passively
  • Grip strength: Reduced due to pain
  • Neurovascular: Sensation intact radial and ulnar digital nerves; capillary refill < 2 seconds at fingertip

• X-ray — Right Ring Finger (3 views):

  • Finding: Non-displaced, cortical crack fracture at the radial base of the proximal phalanx, right ring finger
  • No articular surface involvement; no volar plate avulsion identified; no rotational deformity

A (Assessment)

1. S62.661A — Nondisplaced fracture of base of proximal phalanx of right ring finger, initial encounter for closed fracture

P (Plan)

1. Buddy taping: Ring finger buddy-taped to middle finger with foam between fingers; adequate padding applied; technique demonstrated and patient able to replicate
2. Splinting: Ulnar gutter splint applied in position of function (MCP at 70°, IP joints at 20° flexion)
3. Medications: Ibuprofen 600 mg PO TID x 5–7 days with food; acetaminophen 500–1000 mg q6h PRN breakthrough pain
4. Ice: 20 minutes on/off for first 48 hours
5. Activity: No sports or athletic activities for minimum 4 weeks; keep hand elevated when resting
6. Orthopedic follow-up: Urgent referral to hand/orthopedic surgery within 3–5 days for follow-up X-ray and definitive management plan
7. Return precautions: Return immediately if develops increased deformity, worsening neurovascular symptoms (numbness, tingling, color change), or significant splint discomfort
8. Patient education: Reviewed signs of compartment syndrome; importance of orthopedic follow-up emphasized

S (Subjective) Patient is a 40-year-old female presenting with acute onset of widespread hives and mild lip swelling approximately 30–40 minutes after eating at a new Asian restaurant. Reports severe itching (8/10). Denies throat tightness, voice change, difficulty swallowing, shortness of breath, chest tightness, wheezing, dizziness, nausea, or abdominal cramping. Possible allergen unknown — new restaurant, may have had sesame or tree nuts. No known prior food allergies. No prior anaphylaxis. Does not carry an epinephrine auto-injector. Not pregnant. No ACE inhibitor use (ACE-i angioedema excluded).

O (Objective)

• Vital Signs (initial):

  • BP: 124/80 mmHg
  • HR: 104 bpm (mild tachycardia)
  • Resp: 18/min
  • SpO2: 99% on room air

• Physical Exam:

  • General: Anxious but speaking in full sentences; no stridor; no respiratory distress
  • Skin: Diffuse urticaria (raised, erythematous, blanching wheals) covering trunk, arms, and anterior thighs; no angioedema of extremities
  • HEENT: Mild lip swelling (lower lip approximately 1.5x normal); no tongue swelling; uvula midline; no oropharyngeal edema; voice normal
  • Pulmonary: Clear to auscultation bilaterally; no wheeze; no stridor
  • Cardiovascular: Tachycardic; regular rhythm; no hypotension
  • Abdomen: Soft; non-tender; no rigidity

A (Assessment)

1. T78.1XXA — Other adverse food reactions, initial encounter
2. L50.0 — Allergic urticaria with angioedema (mild–moderate; no anaphylaxis criteria met — no hemodynamic instability, no respiratory compromise)

P (Plan)

1. Diphenhydramine: 50 mg IM given in office (rapid onset); patient monitored for 60 minutes post-administration
2. Cetirizine: 10 mg PO given in office (long-acting H1 blocker); continue 10 mg daily PO x 5–7 days for urticaria
3. Famotidine: 20 mg PO given in office (H2 blocker); continue 20 mg BID PO x 5 days
4. Epinephrine: NOT administered (criteria for anaphylaxis not met); patient educated on when self-administered epinephrine would be appropriate
5. Monitoring: Patient observed x 60 minutes; urticaria improved 50%; lip swelling resolving; vitals normalized; SpO2 stable; cleared for discharge
6. Epinephrine auto-injector prescription: Prescribed EpiPen 0.3 mg x2 auto-injectors; demonstrated technique; instructed to carry at all times; emergency action plan reviewed
7. Allergy referral: Referred to allergist for food allergy panel and evaluation; appointment recommended within 2 weeks
8. Return precautions (critical): Return to ED immediately or call 911 if develops: throat tightness, voice change, difficulty breathing, dizziness, or rapid spread of symptoms
9. Patient education: Medic Alert bracelet recommended; reviewed common hidden allergens (sesame, tree nuts); restaurant communication tips reviewed

S (Subjective) Patient is a 30-year-old male with a painful lump on his left lower back that has been present for 5 days. Initially a small "pimple" that progressively enlarged. Now reports significant pain (7/10) and warmth at the site. Denies fever at home. No recent trauma to the area. No recent travel. No known MRSA history or exposure. Not immunocompromised. No diabetes. Took ibuprofen without significant pain improvement.

O (Objective)

• Vital Signs:

  • Temp: 37.3°C (afebrile)
  • BP: 122/78 mmHg
  • HR: 86 bpm

• Skin Exam — Left Lower Back:

  • Location: 5 cm lateral to L4 spinous process, left
  • Inspection: Erythematous, indurated nodule 3 x 4 cm; central pustule with overlying thin skin; no tracking cellulitis extending beyond 1 cm of surrounding erythema; no regional lymphadenopathy
  • Palpation: Tender; fluctuant; no crepitus; no woody induration (no necrotizing fasciitis features)

• Procedure — Incision and Drainage (I&D):

  • Area cleansed with povidone-iodine
  • Local anesthetic: 5 mL 1% lidocaine with epinephrine; field block around abscess cavity
  • Incision: 1.5 cm linear incision made at point of maximal fluctuance with No. 11 blade
  • Drainage: ~8 mL purulent material expressed; specimen sent for C&S
  • Wound exploration: No tracking cavities identified; no foreign body
  • Irrigation: Cavity irrigated with 60 mL NS; packing with plain gauze strip (1/4 inch)
  • Dressing: Dry gauze dressing applied over packing

A (Assessment)

1. L02.212 — Cutaneous abscess of back (left) — incision and drainage performed
2. Community-acquired etiology most likely; wound culture pending

P (Plan)

1. Antibiotics: TMP-SMX DS (160/800 mg) 1 tablet PO BID x 7 days (empiric MRSA coverage per IDSA guidelines for skin abscess in healthy adult)
2. Wound packing: Packing to be removed in 48–72 hours; patient instructed on how to follow up or have packing removed
3. Pain management: Ibuprofen 600 mg PO TID x 5 days with food; acetaminophen PRN breakthrough pain
4. Wound care: Keep outer dressing clean and dry; change daily if soiled; warm compresses to area QID
5. Culture follow-up: Will call in 48–72 hours to review C&S results; antibiotic adjusted if resistant organism identified
6. Return precautions: Return immediately if fever develops, increasing redness/warmth beyond current margin, significant increase in pain, or development of crepitus or skin discoloration (necrotizing fasciitis signs)
7. Follow-up: Packing removal at urgent care in 48–72 hours; wound check in 5 days

S (Subjective) Patient is a 55-year-old male with known hypertension and hyperlipidemia presenting with 2 hours of substernal chest pressure, 6/10 intensity, non-pleuritic, onset at rest while watching television. Reports mild dyspnea but no diaphoresis, nausea, or vomiting. Denies radiation to arm or jaw. Pain has not changed since onset. No prior cardiac history; no prior MI or stents. Medications: Amlodipine 5 mg daily, Atorvastatin 20 mg daily. Family history: Father with MI at age 62. Current smoker (15 pack-year). No known drug allergies. Not taking aspirin regularly.

O (Objective)

• Vital Signs:

  • BP: 158/92 mmHg
  • HR: 96 bpm
  • Resp: 18/min
  • SpO2: 97% on room air
  • Temp: 37.1°C

• Physical Exam:

  • General: Middle-aged male, mild distress; diaphoresis noted on exam
  • Cardiovascular: Tachycardic; regular rhythm; S1/S2 normal; no S3/S4; no murmur; no JVD; peripheral pulses 2+ bilaterally
  • Pulmonary: Clear to auscultation bilaterally; no rales or wheeze
  • Abdomen: Soft; non-tender; no pulsatile mass

• Diagnostics (performed in urgent care):

  • 12-Lead ECG: Sinus tachycardia at 96 bpm; no ST elevation; no ST depression; no T-wave inversions; no LBBB (normal ECG)
  • Troponin I (high-sensitivity): 0.04 ng/mL — at upper reference limit (indeterminate — cannot rule out NSTEMI in urgent care setting)
  • Aspirin 325 mg PO given in office after ECG obtained

A (Assessment)

1. R07.9 — Chest pain, unspecified — rule-out ACS in patient with multiple cardiac risk factors
2. Indeterminate troponin; cannot safely rule out NSTEMI in urgent care setting; serial troponin and monitoring required
3. Hypertension — elevated BP; not acutely managed in this setting given need for ED transfer

P (Plan)

1. Transfer to ED: Patient transfer arranged via ambulance to [local hospital ED] for serial troponin measurement, continuous cardiac monitoring, further cardiac workup (CCTA or stress testing), and potential cardiology consultation
2. Communication: Spoke with ED attending Dr. [name] by phone; verbal handoff completed; patient status and test results communicated
3. Aspirin given: ASA 325 mg PO administered in office
4. IV access: Peripheral IV placed prior to transfer (18G right AC)
5. IV fluids: Normal saline at KVO rate during transport
6. Patient/family informed: Discussed clinical concern and necessity of ED transfer; patient and wife verbalized understanding; patient verbalized consent to transfer
7. Documents sent: Copy of ECG, vital signs log, and this note transmitted to receiving ED

S (Subjective) Patient is a 16-year-old male who sustained a head-to-head collision during a high school football game approximately 1 hour ago. Reports immediate dizziness and confusion lasting approximately 2–3 minutes; no loss of consciousness per coaches and teammates who witnessed the incident. Currently reports headache (frontal, 5/10), feeling "foggy," mild nausea, and sensitivity to light. Denies vomiting (no episodes). Denies neck pain. Denies extremity weakness or numbness. Prior concussion history: none. Athlete uses standard football helmet (fit checked by athletic trainer last month). Parents accompanying patient; coach provided sideline report. Current medications: None. No blood thinners.

• ImPACT Baseline on File: Yes (taken preseason — values available)

O (Objective)

• Vital Signs:

  • BP: 118/72 mmHg
  • HR: 76 bpm
  • Resp: 16/min
  • GCS: 15 (E4V5M6)

• Physical and Neurological Exam:

  • Mental Status: Alert, oriented x4; slightly slowed processing speed noted on questioning; no confusion at this time; SCAT5 symptom score = 14/132 (significant)
  • HEENT: No scalp lacerations or contusions; no periorbital ecchymosis; no Battle's sign; TMs clear bilaterally; pupils 4 mm, equal and reactive bilaterally
  • Cervical Spine: No midline tenderness; full ROM; no step-off
  • Cranial Nerves: II–XII grossly intact
  • Motor: 5/5 strength all extremities
  • Sensation: Intact to light touch throughout
  • Coordination: Finger-nose-finger with mild dysmetria (compared to baseline); tandem gait mildly unsteady
  • Balance: BESS testing: Single leg stance 20 seconds (vs. baseline 25 seconds), tandem stance 25 seconds

• SCAT5 Maddocks Questions: 2/5 correct (failed orientation to quarter and score — not recalled)

• CT Head: NOT indicated per Canadian CT Head Rule / Pediatric Emergency Care Applied Research Network (PECARN) — no LOC, GCS 15, no vomiting ≥ 2 episodes, no severe mechanism

A (Assessment)

1. S09.90XA — Concussion, initial encounter (meets diagnostic criteria: biomechanical force to head with ≥1 symptom from headache, cognitive impairment, and balance dysfunction clusters; GCS 15)
2. No red flag features requiring ED transfer at this time

P (Plan)

1. Immediate removal from play: Patient removed from game and not to return today; confirmed with parents and athletic trainer
2. Observation: Patient observed in urgent care for 2 hours; neurological status stable throughout; no vomiting
3. Return to school: May return to school when symptom-free at rest; recommend cognitive rest (no heavy studying, screen time) for 24–48 hours; gradual cognitive load increase as tolerated
4. Return-to-play (RTP) protocol: Strict adherence to school's graduated 6-step RTP protocol; minimum 5 days before return to contact practice; may not return until symptom-free + successful RTP progression + cleared by licensed healthcare provider
5. Parents instructed: Wake-check protocol (rouse every 2–3 hours overnight first night; return to ED if unable to awaken, severe headache, repeated vomiting, increasing confusion, weakness, or slurred speech)
6. ImPACT retest: Schedule post-concussion ImPACT retest in 3–5 days; compare to preseason baseline for RTP clearance decision
7. School letter: Provided return-to-learn letter for school staff with temporary academic accommodations (extra time, reduced workload, quiet testing environment)
8. Follow-up: PCP or sports medicine physician in 3–5 days for reassessment; sooner if red flags develop
9. Concussion return-to-ED precautions given verbally and in writing to both patient and parents