Coma HISTORY_LIST comatose obtunded stupor coma confusion hallucinations IV glucose response clouded thinking agitation photophobia onset activity prior to onset trauma suicide attempts depression epilepsy post ictal state fever vertigo nausea vomiting chest pain cough INFECTIOUS DISEASES meningitis encephalitis otits media CHRONIC DISEASE dementia stroke TIA hypertension renal dz. liver dz. cardiac dz. SURGERY neurosurgery PREVIOUS TESTS CT scan of head EEG TRAUMA OR INJURIES head trauma MVA's SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal MEDS_LAB_TESTS **** MEDS insulin hypoglycemic narcotics antipsychotics steroids anticholinergics cimetidine anticoagulants **** LAB glucose electrolytes calcium BUN Cr ABG ammonia blood alcohol level LFT urine toxicology screen B12 folate **** TESTS EEG MRI/CT of head REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge REVIEW_OF_SYSTEMS_3 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty in fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts psychiatric hospitalizations personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia PHYSICAL_EVAL_1 VITALS BP Pulse Temp GENERAL oriented X GLASGOW COMA SCALE Verbal Response none - 1 incomprehensible sounds/cries - 2 appropriate words/verbal sounds - 3 confused speech or words - 4 oriented speech - 5 Eye Opening Response no eye opening - 1 eyes open to pain - 2 eyes open to speech - 3 eyes open spontaneously Motor Response none - 1 abnormal extension to pain - 2 abnormal flexion to pain - 3 withdraws to pain - 4 localization to pain - 5 SKIN dry clammy rash cyanosis jaundice spider angiomata spider hemorrhage palmar erythema petechia localized fat atrophy HEENT skull tenderness hematoma lacerations lacerations PERRLA EOMI corneal reflex Raccoon sign (periorbital ecchymosis) hemotypanum tongue laceration cheek laceration pallor atrophic tongue PHYSICAL_EVAL_2 NECK neck rigidity carotid pulse amplitude carotid pulse duration carotid bruits thyroid enlargement lymphadenopathy CHEST Cheyne-Stokes breathing pattern hyperventilation barrel chest rhonchi fine crackles course crackles wheezes HEART regular rate & rhythm S3 gallop rubs murmurs ABDOMEN tenderness distention dilated superficial veins masses ascites hepatomegaly RECTAL guaiac (occult blood) EXTREMITIES track marks sclerotic veins NEURO SKIN dry clammy rash cyanosis jaundice spider angiomata spider hemorrhage palmar erythema petechia localized fat atrophy DIFF_DIAGNOSIS Electrolyte imbalance hyperglycemia hypoglycemia/insulin overdose alcohol/drug treatment arrhythmia hypoxia hypercapnia anemia meningitis encephalitis systemic infection cerebrovascular dz. intracranial hemorrhage thrombophlebitis exacerbation of dementia narcotic overdose anticholinergic overdose analgesic overdose sedative overdose antiarrhythmic overdose steroid withdrawal hypotension hepatic encephalopathy psychotic states dehydration hypertensive encephalopathy head trauma subdural hematoma vitamin deficiency malnutrition uremia hypo/hyperthyroidism adrenal failure ketoacidosis acidosis alkalosis factitious coma