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S: Athlete was at basketball practice and says he took a charge and hit his head on the
court. Pt. says he has a slight headache and a little dizziness going on. There was no LOC
and athlete has not had this happen to him before.

O: No bleeding or physical signs of trauma. ABC’s were all normal. Athlete was able to
sit up and was reassessed and then stood up and was reassessed. Everything was normal
with this and no pain noted when getting up. Neurological tests: Smelling was good,
Hearing was good. No problems with clenching teeth, shrugging shoulders, smiling or
frowning. Athlete was taken to the bench and sat down for 15 minutes. After 15 minutes
Athlete says the symptoms went away. Athlete was told to perform some exertional
activities. Athlete performed 15 push-ups and 15 sit ups. Then athlete performed 10 side-
court shuffles. Athlete said dizziness and headache were starting to return.

A: DD: MTBI (Concussion), Coup, Contracoup.
WD: MTBI (Concussion)

P: Athlete will not be participating for the rest of this practice, and will be sent home to
rest and see a doctor. Participation will be based on instructions from the doctor and
depending on if the athlete’s symptoms return or not. Athlete will take an IMPACT test
and results will be a factor in determining when athlete will be able to practice and play
again. Asked athlete to check up with me tomorrow (4/29/15), to see if symptoms
continue. Athlete will not be doing any kind of exertional activities or practice until all
symptoms are gone and athlete is cleared by doctor.
_Omar Ramos, ATS_