CHIEF COMPLAINT: Syncope x .... minutes or days
HISTORY OF PRESENT ILLNESS:
Onset -
Character -
Position - sitting , supine , standing (circle one)
It lasted ... min
Loss of consciousness -
Seizure activity -
Witnessed -
Confused after the event -
Incontinent of urine/bowel -
Injury -
Sx before the episode:
Lightheadedness -
Racing heart -
Chest pain -
Vision problems -
Nausea/Vomiting/Diarrhea -
Headache -
Abdominal pain -
Black/bloody stools -
Fever/chills -
SOB -
Similar symptoms before -
ER Tx given -
Advanced directives:
Reliability of the informant:
PAST MEDICAL HISTORY: (circle all that apply)
MI CAD CABG HTN CHF EF DM Hyperchol. Dilated CMP Pacemaker
Stroke Arrhythmias
Stress test -
2D-Echo -
Catheterization -
When - Where -
CA PUD PVD DVT COPD Asthma Gallstones EGD Colonoscopy
PAST SURGICAL HISTORY: (circle all that apply)
CABG Valve surgery
Cholecystectomy Hernia GSW Hysterectomy C-section
MEDICATIONS:
ALLERGY: NKDA
FMH:
CAD DM Stroke HTN CA
SOCIAL HISTORY: (circle all that apply)
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:
Ortostatics -
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
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= INR- AG= LFT
Cardiac enzymes x 1-negative Mg++ TSH
BNpep - UA: Lipids: LDL HDL
Old CXR:
CXR:
Old EKG:
EKG on admission:
EKG later:
Telemetry monitor:
A R A R E P Q R S T
D R I I E E
CT head:
ASSESSMENT:
- Syncope due to
*vasovagal episode
*TIA
*Arrhythmia
*Seizure
PLAN:
- Telemetry
- Cardiac enzymes x 2 q 8hr
- EKG now and in AM
- 2D Echo
- Carotid duplex
- UA
- Home meds (check the list)
- Heparin 5000 U SQ BID or Lovenox 40 mg SQ daily
- Cardiology consult as an outpatient or inpatient
- Neurology consult as an outpatient or inpatient
Signature:
Published: 02/11/2005
Updated: 03/08/2009
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