HISTORY:
for
Severity:
Pattern: ,
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
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: , , , , , ,
- Sleep study
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-
-
-
- Stretching exercises before bed
- Regular exercise
- Good sleep hygiene
- Avoidance of caffeine
- Avoidance of alcohol
- Smoking cessation counseling
- Referral to neurologist
- Referral to sleep specialist
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as pain or numbness, or if symptoms do not improve with treatment