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How Do You Make the Diagnosis of Concussion?

To make a diagnosis of concussion, you need a reliable history of 2 things: (1) An acute external physical force applied to the brain AND (2) An impairment in the function of the brain directly caused by the external physical force. One or the other is not enough. You need both. You do not need a scan or lab test to make the diagnosis. No scan or test can “rule in” or “rule out” concussion. You do not need to perform a detailed neurological exam to make the diagnosis. The neurological exam is usually unremarkable except for immediately after the concussion. No exam findings “rule in” or “rule out” concussion.
 A collateral source is key to obtaining a reliable history. The impairment in brain function occurs immediately after the event. The impairment is worst immediately after the event, then gradually improves. There is no other obvious explanation for the impairment.