SIEZURE HISTORY_LIST onset duration description of seizure aura pallor incontinence of urine incontinence of feces salivation vomiting aspiration post-ictral weakness post-ictal paralysis visual changes paresthesias lethargy disorientation somnolence stiff neck lipsmacking leg movement teeth clenching INFECTIOUS DISEASES sinusitis CHRONIC DISEASES OR DISORDERS past seizures TIA's stroke migraine headaches diabetes hypertension hypocalcemia hypoglycemia hypomagnesemia vasculitis SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal MEDS_LAB_TESTS **** MEDS meperidine overdose high dose penicillin phenothiazines lithium lidocaine anticholinergics antihistamines antidepressants salicylates amphetamines insulin oral hypoglycemics theophylline propranolol isoniazid PCP carbon monoxide lead ingestion pesticides **** LAB serum alcohol anticonvulsant levels Electrolytes BUN creatnine glucose calcium magnesium CBC LFT UA urine toxicology **** TESTS EEG MRI/CT scan lumbar puncture RPR/VDRL 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 lethargy SKIN cafe-au-lait neurofibromas splinter hemorrhages unilateral port-wine facial nevus facial angiofibromas hypopigmented ash leaf spots shareen patches periungual fibromas spider angiomas malar rash needle marks HEENT pigmented iris hamartomas head trauma PERRLA nystagmus EOMI visual fields papilledema venous pulsations gum hyperplasia tongue lacerations buccal lacerations temporal bruits carotid bruits neck rigidity PHYSICAL_EVAL_2 CHEST rhonchi crackles wheezes HEART regular rate & rhythm murmur S3 GU incontinence of urine incontinence of feces RECTAL guaiac (occult blood) EXTREMITIES cyanosis bone pain fractures NEURO dysarthria able to follow commands sensory weakness pinprick coordination cranial nerves Babinski's sign Rhomberg's sign DIFF_DIAGNOSIS Noncompliance with anticonvulsants hypoglycemia hyponatremia hypocalcemia hypomagnesemia hypertensive encephalopathy alcohol/barbiturate withdrawal meningitis encephalitis uremia pyridoxine deficiency osmolar disturbances trauma arterivenous malformation brain tumor genetic disorder congenital malformation cerebrovascualr disease stroke hepatic failure uremia vasculitis pseudoseizure