CVA & Weakness HISTORY_LIST gradual onset of weakness sudden onset of weakness time of onset location of deficit activity prior to onset prior headache nausea vomiting loss of consciousness brisk neck movements visual aura scotoma blurred vision diplopia vertigo seizure paresthesia neck stiffness fever confusion dysarthia incontinence dysphagia transient monocular blindness heart palpitations CHRONIC DISEASE OR DISORDERS prior TIA stroke hypertension diabetes coronary disease endocarditis hyperlipidemia heart failure valvular dz. arrhythmias (A. fib) claudication migraine headaches PREVIOUS TESTS CT scan carotid Doppler echocardiogram TRAUMA OR INJURIES head injuries SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine IV drug use ALLERGY medications foods seasonal FAMILY HISTORY stroke hyperlipidemia cardiac dz. MEDS_LAB_TESTS **** MEDS anticoagulants oral contraceptives antihypertensives **** LAB Electrolytes BUN creatnine CBC ESR **** TESTS ECG CXR MRI CT scan 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 R arm BP L arm Pulse Temp GENERAL lethargy SKIN petechia splinter hemorrhages HEENT PERRLA pin-point pupils enlarged pupils EOMI hypertensive retinopathy yellow retinal flecks Roth spots subhyloid retinal hemorrhages retinal exudates papilledema venous pulsations temporal bruits facial symmetry facial weakness corneal reflex in tact NECK neck rigidity carotid bruits asymmetrical carotid pulse vertebrobasilar bruits PHYSICAL_EVAL_2 CHEST clear to auscultation bilaterally rhonchi fine crackles course crackles wheezing Cheyne Stokes breathing pattern HEART regular rate and rhythm irregular, irregular rhythm S3 murmurs ABDOMEN tenderness aortic pulsations renal bruits RECTAL guaiac (occult blood) EXTREMITIES unequal peripheral pulses edema cyanosis clubbing all pulses 2+/4 bilaterally radial pulse ulnar pulse femoral pulse popliteal pulse posterior tibial pulse dorsalis pedis pulse Homan's sign varicosities NEURO weakness in arm weakness in leg gag reflex CN II-XII grossly intact CN palsy CN I intact CN II intact CN III intact CN IV intact CN V intact CN VI intact CN VII intact CN VIII intact CN IX intact CN X intact CN XI intact CN XII intact gaze pstosis pinprick light touch gait normal gait abnormal upper extrem strength bilat. equal upper extremity DTR's 2+ bilat. lower extrem strength bilat. equal lower extremity DTR's 2+ bilat. Babinski's sign superficial touch sensation deep pressure superficial pain positional sense vibration sense temperature Romberg Test rapid rhythmic alternating movements finger-to-finger test finger-to-nose test heel-to-shin test stereognosis two-point discrimination extinction phenomenon graphesthesia point location nuchal rigidity Brudinski's sign Kernig's sign DIFF_DIAGNOSIS TIA Brain abscess Meningitis Encephalitis subdural hematoma Hypoglycemia demylination dz. vasculitis postictal paralysis delirium hysteria conversion reaction atypical migraine basilar artery stenosis carotid steal syndrome SIGNS OF CEREBRAL HERNIATION Obtundation, dilation of ipsilateral pupil, decerebrate posturing Cushing's Triad = bradycardia, hypertension, abnormal respiration; ascending weakness SIGNS OF INC INTRACRANIAL PRESSURE Lethargy, headache, vomiting, meningismus, visual changes, gait disturbances, cranial nerve palsy, papilledema, focal neurologic deficits, abnormal vital signs, seizures, hyperreflexia, head tilt.