HISTORY:
Episodes of for
Onset: , following
Severity:
Pattern:
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , ,
- ECG
-
-
-
- Cognitive behavioral therapy
- Mindfulness and relaxation techniques
- Regular exercise
- Good sleep hygiene
- Avoidance of caffeine and other stimulants
- Avoidance of alcohol
- Avoidance of cannabis
- Avoidance of drugs
- Referral to psychologist
- Referral to psychiatrist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or suicidal thoughts