HISTORY:
Decreased level of consciousness for
Onset:
Event:
Witnessed by , and described as
Last known normal ago
Associated symptoms:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic:
- Mental status: , oriented in , speech
- Cranial nerves:
- Strength: upper extremities -R /5 , -L /5
lower extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L ,
lower extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
patellar -R , -L , achilles -R , -L , plantar -R , -L
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike ,
- Gait: , tandem walking , heel and toe walking
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , ,
- Urinalysis
- Chest X-ray
- ECG
- CT scan of the head
- MRI of the brain
- EEG
- Lumbar puncture
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-
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-
-
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- Continuous monitoring of vital signs
- ICU admission
- Referral to neurology
- Referral to toxicology
- Referral to critical care
- Follow-up in
- Return if level of consciousness decreases further or if new symptoms such as seizures, focal neurological deficits, or respiratory distress develop