Critical: Taking a Detailed Case History

If your patient's symptoms lead you to suspect a concussion/mTBI, it can be helpful to determine if your patient served in the military. If so, ascertain if your patient experienced a blast, vehicle crash, or fall — any trauma that might have caused a concussion/mTBI. (Please remember that these injuries also happen away from the field of battle — on base or off duty.) If you discover a possible triggering event, then making the diagnosis requires assessing your patient's level of consciousness and symptoms in the past, right after the trauma. This can only be accomplished by getting a good case history or chronology of the incident.

To take a good case history, allow your patient to narrate the story; but question him or her in sufficient detail to uncover any gaps in your patient's memory or consciousness following the trauma. Remember from an earlier page that two of the diagnostic criteria are a loss of consciousness and loss of memory.

Watch this short demonstration of how to take a case history with Dr. Wendy Law, clinical neuropsychologist at the Walter Reed National Military Medical Center, and a Marine Corporal who sustained a concussion/mTBI in Afghanistan:

How to Unearth What Happened at the Time of Injury

Diagnosis of TBI is based on what happened at the time of injury. It is often hard for service members to remember the moment-by-moment details.

NOTE: The name of the service member is not included to protect his confidentiality.

* Additional resources: Watch Dr. Wendy Law, clinical neuropsychologist, conduct a full case history with a Marine Corporal and a Marine Sergeant.