Once you have the patient's history, carefully consider the criteria of diagnosing concussion/mTBI from the previous pages. It is evident that your patient has sustained a concussion/mTBI if he or she reports loss of consciousness or blacking out (even for a few seconds but less than 30 minutes). Post-traumatic amnesia (not remembering a period of time before or after the event) is easily identified too, but distinguishing alteration of consciousness (AOC; confusion, disorientation) is challenging at times. AOC should not be confused with a normal psychological response to stress, such as feeling startled or stunned by a sudden event.
Once you have determined your diagnosis, you can assess the current symptomatology by using two clinical tools:
- The Neurobehavioral Symptom Inventory (NSI) Form is a validated measure that captures information on 22 common subjective complaints which may occur following TBI.
- The PTSD Checklist (PCL) is a 17-item, self-report measure of the 17 DSM-IV symptoms of PTSD (or acute stress disorder depending on the length of time following the TBI).
The combination of both of these questionnaires is useful in identifying the critical needs of your patient and guiding the treatment plan.