Admission Note for Change in MS

DATE:

CHIEF COMPLAINT: Change in mental status x

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-

Baseline-
Similar symptoms before-

Head injury-
Nausea- , Vomiting- , SOB- , CP-
Headache- , Passed out- , Seizure- , Dizzy-
Cough- , Fever/chills- , Palpitations- , Dysuria-

ER Tx given-

PAST MEDICAL HISTORY:
MI CAD CABG HTN CHF EF DM Hyperchol. Dilated CMP Pacemaker
Stroke Arrhythmias Migraine Seizures

Stress test-
2D-Echo-
Catheterization-
When- Where-

CA PUD PVD DVT COPD Asthma Gallstones EGD Colonoscopy

PAST SURGICAL HISTORY:
CABG Valve surgery
Cholecystectomy Hernia GSW Hysterectomy C-section

MEDICATIONS:

ALLERGY: NKDA

FMH:
CAD<> 55 yo DM Stroke HTN CA Migraine

SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker: no
Illicit drugs- no cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarkable apart from above symptoms

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= B= L= AG= LFT
CPP x 1 - negative
Plasma osmolality- Osmolar gap-
Urine toxic screen-
EtOH level-Acetaminophen-Salicylates-
UA:
CT head:
CXR:
EKG:


ASSESSMENT:
-Baseline-

-Change in mental status due to
*Infection-
*Volume depletion
*Hypernatremia
*TIA
*CVA
*Seizure
*Subdural hemorrhage

-Swallow evaluation at bedside-

PLAN:
-CPP x 2 q 8 hr
-EKG now and in AM
-ASA
-UA
-Tylenol 650 mg PO q 4-6 hr PRN headache
-Vasotec 1.25 mg IV q 6 hr PRN SBP> 160

Signature:

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Related:

Stroke/TIA order set. Happy Hospitalist, 08/2008.

Published: 02/11/2005
Updated: 08/11/2008