HISTORY:
for
, up to °, over
, , , ,
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , ,
- CT scan of the head
- Lumbar puncture
- Nasopharyngeal swab for viral PCR
- Chest X-ray
- Urinalysis and culture
- IV fluids
-
-
-
-
-
-
- Admission to intensive care unit
- Referral to infectious disease specialist
- Referral to neurologist