CHIEF COMPLAINT: Dizziness x
HISTORY OF PRESENT ILLNESS:
Onset-
Character-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
New weakness-
Altered sensation-
Vision problems- , Double vision-
Impaired speech/swallowing-
Decreased ability to stand/walk-
Falling-
Altered mental status-
Sense of movement-
Off-balance-
Faint/lighheaded-
Blacked out-
Sense of confusion-
Headache-
Hearing loss- , Ringing/roaring in in ear-
Ear pain-
Baseline-
Similar symptoms before-
Head injury-
Nausea- , Vomiting- , SOB- , CP-
Headache- , Passed out- , Seizure- , Dizzy-
Cough- , Fever/chills- , Dysuria- , Black/bloody stools-
Diarrhea-
Abdominal pain-
ER Tx given-
PAST MEDICAL HISTORY:
MI CAD CABG HTN CHF EF DM Hyperchol. Dilated CMP
Pacemaker
Stroke Migraine Seizures Ear problems Arrhythmias
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 apartffrom 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:
CPP x 1-negative
CT head:
CXR:
EKG:
A R A R E P Q R S T
D R I I E E
ASSESSMENT:
-Dizziness due to
*Hypovolemia
*Arrhythmia
*TIA
*Labyrinthitis
*CVA
*Subdural hemorrhage
PLAN:
-CPP x 2 q 8 hr
-EKG now and in AM, telemetry
-ASA
-UA
-Home meds
-Neurolgy consult
-Tylenol 650 mg PO q 4-6 hr PRN pain
-Vasotec 1.25 mg IV q 6 hr PRN SBP> 160
-Heparin 5000 U SQ BID
- Tilt table test
Signature:
Created: 2/2005
Updated: 03/08/2007
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