CHIEF COMPLAINT:
Change in mental status x ............. hours/days
Agitated x ............. hours/days
Hallucinating x ............. hours/days
Tremor x ............. hours/days
HISTORY OF PRESENT ILLNESS:
Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
New weakness -
Altered sensation -
Vision problems -
Impaired speech/swallowing -
Decreased ability to stand/walk -
Falling -
Pain -
Baseline -
Similar symptoms before -
Situational problems - family work homeless legal
Chronic EtOH/drug dependence -
Substance taken:
route -
amount -
frequency -
duration -
date of last use -
Head injury -
Nausea - , Vomiting - , Diarrhea - , SOB - , Chest pain -
Headache - , Passed out - , Seizure - , Dizzy -
Cough - , Fever/chills - , Palpitations - , Dysuria -
Shakes - ,
Depression - , Suicidal/homicidal thoughts -
Confused/hallucinating -
Pregnant -
ER Tx given -
PAST MEDICAL HISTORY: (circle all that apply)
MI CAD HTN DM Stroke Migraine Seizures
Psych.problems Suicide attempts
Catheterization Echo
Pacemaker CA PUD PVD DVT COPD Asthma Gallstones Cirrhosis
EGD Colonoscopy
PAST SURGICAL HISTORY: (circle all that apply)
CABG Cholecystectomy Hernia GSW Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH: (circle all that apply)
CAD DM Stroke HTN CA Migraine
SOCIAL HISTORY: (circle all that apply)
Independent NH Lives w spouse son daughter
Alcohol - heavy occasional last drink
Smoker:
Illicit drugs - cocaine heroin marijuana
REVIEW OF SYSTEMS: not remarkable apart form the symptoms above
PHYSICAL EXAM:
VITALS: Orthostatics -
SpO2 - Initial vitals -
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
Rectal exam:
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal
LABS:
N= L= B= AG= LFT
Plasma osmolality - Osmolar gap -
Urine toxic screen -
EtOH level - Acetaminophen - Salicylates -
CT head:
CXR:
EKG:
ASSESSMENT:
- Baseline -
- Change in mental status due to
Intoxicated
Infection-
Volume depletion
Hypernatremia
TIA
CVA
Subdural hemorrhage
- Swallow evaluation at bedside -
PLAN:
- Cardiac enzymes x 2 q 8 hr
- EKG now and in AM
- Aspirin
- UA
- Tylenol 650 mg PO q 4-6 hr PRN headache
- Vasotec (enalapril) 1.25 mg IV q 6 hr PRN SBP higher than 160 mmHg
Signature:
Published: 02/03/2005
Updated: 03/08/2009
No comments:
Post a Comment