HISTORY:
for
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Extremities: , , cap refill , pulses ,
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: , , , , , ,
- ECG
- CT scan of the head
- MRI of the head
- Carotid ultrasound
- Echocardiogram
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-
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-
-
- Physiotherapy
- Speech therapy
- Occupational therapy
- Referral to neurologist
- Referral to physiatrist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as severe headache, sudden vision changes, or sudden weakness or numbness