HPI=LIQ
(ODPFTC
C/I)
R
AGG
ALL
ASSOCIATED,

RAMPPS=
ROS,ALL,
MED,PMH/FH,PSH,SH
(SODA)


NEUROLOGICAL
CASES

CONFUSION
AND
MEMORY
LOSS:

ASSOCIATED
SYMPTOMS:
HPI,RAMPPS
DESCRIPTION,
SUDDEN
OR
GRADUAL,
DEATH
SHAFT,
ANY
PAIN,

WEAK,
NUMB,
TINGLING,
DECREASED
SENSATION,
WALKING,
TALKING,
SHAKING,
SPEECH,
CONFUSION,

DEPRESSION,
BP,
VISION,
FAINTING,
LIGHTHEADED,
FALLS,
CLUMSINESS,
DIZZYNESS,
FATIGUE,
WEIGHT,

APPETITE,
HOT,
COLD.
HPI
AND
RAMP.
ROS:OBGYN,
CP,
SOB,
ABPN,
N,V,D,C,URINATION,

CONFUSION/MEMORY
LOSS

DD:
ASH
VI
BDNS














































 WORK
UP
 
 
 PE:INSPECT/PALPATE

ALZHEIMERS
 
 
 
 
 CBC
W/
DIFF
 
 
 HEENT/MME

SUBDURAL
HEMATOMA

 
 
 ESR,
ELYTES,
GLUCOSE
 
 EYE/FUNDO

HYPOTHYROID,
HYPOGLYCEMIA

 
 CT
HEAD

 
 
 CAROTIDS

VASCULAR
DEMENTIA
 
 
 
 MRI
BRAIN
 
 
 CV/PUL

INTRACRANIAL
BLEED
 
 
 
 SERUM
B12
 
 
 AB

B12
DEFICIENCY

 
 
 
 TSH
 
 
 
 NEURO/MME,CN

DEPRESSION,DELIRIUM
 
 
 
 EEG
 
 
 
 MOT,
REF,
SEN,CER,GAI

NP
HYDROCEPHALUS
 
 
 
 
 
 
 
 ROMBERG

STROKE



DIZZINESS

ASSOCIATED
SYMPTOMS:
DIZZYNESS,
HEARING
LOSS
AND
EAR
PAIN

HPI,
RAMPPS,
ASSOCIATED:
DESCRIPTION,
DO
YOU
HAVE
EAR
PAIN,POSTIONS
THAT
INCREASE
IT,

POSITIONS
THAT
DECREASE
IT,
UNILATERAL
BILATERAL,
RINGINING,
SPINNING,
HEARING
LOSS,

FULLNESS,
PRESSURE,
EAR
DISCHARGE,
ROS:OBGYN,
HEADACHE,
N,V,
STOOL
CHANGES,
URINARY

CHANGES,
ABD
PAIN,
URI,
INFECTIONS,
TRAUMA,
FALLS,
BALANCE,
MUSCLE
WEAKNESS,
NUMB,

TINGLING,
LOUD
NOISES,
INSERT
FOREIGN
BODY,AIR
TRAVEL,FEVER,
RUNNY
NOSE,
SORE
THROAT,

COUGH,
CP,
SOB.

PMH:
MENIGITIS,
LYME,
SYPHILLIS,
DM



DIZZINESS

DD:
MOB
LAP
 
 
 
 
 WORK
UP
 
 
 PE:
INSPECT
PALPATE

MENIERE’S
DS.
 
 
 
 
 DIX
HALLPIKE
MANEUVER
 HEENT/FUNDO/OTO

ORTHOSTATIC
HYPOTENSION
 
 
 ORTHOSTATIC
VITAL
SIGNS
 MOUTH,THROAT,NECK

BENIGN
POSITIONAL
PAROXYMAL
VERTIGO
 MRI
BRAIN
 
 
 ASSES
HEARING/RINNE

PERILYPHATIC
FISTULA
 
 
 
 AUDIOMETRY
 
 
 WEBER,
WHISPER,


ACOUSTIC
NEUROMA
 
 
 
 VDRL/RPR
 
 
 BEHIND,
SIDES.

LABRINTHITIS
 
 
 
 
 ELECTRONYSTANOGRAPHY
 NEURO:CN,MOT,REF


 
 
 
 
 
 
 
 
 
 ROM,GAIT.

HEARING
LOSS


DD:
COCHLEAR
POOMA

 WORK
UP

COCHLEAR
DAMAGE
 
 CT
HEAD
 

PREBYCUSIS
 
 
 AUDIOMETRY

OTOTOXCIITY
 
 
 TYMPANOGRAPHY

OTOSCLEROSIS
 
 
 BRAINSTEM
AUDIOMETRY

MENEIR’S
DS
 
 
 VDRL/RPR

ACOUSTIC
NEUROMA





EAR
PAIN

DD:
COMET
 
 
 
 
 WORK
UP

CERUMEN
IMPACTION
 
 
 
 AUDIOMETRY

OTITIS
EXTERNA
 
 
 
 OTOSCOPY

OTITIS
MEDIA
 
 
 
 
 CBC/URINANALYSIS

MIDDLE
EAR
TUMOR
 
 
 
 CT
HEAD

EAR
CANAL
OBSTRUCTION
 
 
 TYPANOGRAPHY

TEMPORAL
MANDIBULAR
JOINT
INFECTION
 VDRL/RPR





EYE
PAIN
AND
VISION
LOSS

ASSOCIATED
SYMPTOMS:
HPI,
RAMPPS,
DESCRIPTION,
SUDDEN
OR
GRADUAL,
DURATION,
HEADACHES,

DIZZINESS,
BLURRED
VISION,
UNILATERAL,
BILATERAL,
PREVIOUS
VISION
PROBLEMS,
GLASSES,

CONTACTS,
EAR
CHANGES,CLOUDY,
SENSTIVITY
TO
LIGHT,NIGHT
VISION,
EYE
PAIN,
DRYNESS,

DISCHARGE,
BRUNING,
REDNESS,
SWELLING,
HALOS.,DEATH
SHAFT(ABILITY
TO
PERFORM
DAILY

ACTIVITIES)
ROS:
N,
V,
WEAKNESS,
NUMB,
TING,
SENSATION,
POLYURIA,
POLYDYPSIA,
POLYPHAGIA,

WEIGHT,
INFECTIONS,
CP,
SOB,
(OBGYN).

PMH:
DM,HTN,
THYROID
DS,
CANCER,




EYE
PAIN
AND
VISION
LOSS

DD:
MD
CAT
HAD
CATARACTS
 
 
 WORK
UP
 
 
 

MACULAR
DEGENERATION
 
 
 CBC
WITH
DIFFER/ESR

DRUG
SIDE
EFFECTS
 
 
 
 FASTING
BLOOD
GLUCOSE

CORNEAL
ABRASION,
CONJUNCTIVITIS
 
 HBA1C

ACUTE
ANGLE
GLAUCOMA
 
 
 URINALYSIS
FOR
PROTEINURIA

TEMPORAL
ARTERITIS
 
 
 
 LIPID
PROFILE

HYPERTENSIVE
RETINOPATHY
 
 
 DOPPLER
OF
CAROTIDS

ANTERIOR
UVEITIS
 
 
 
 SLIT
LAMP

DIABETIC
RETINAPATHY

 
 
 MRI
BRAIN

CATARACTS
 
 
 
 
 CT
HEAD



PHYSICAL
EXAM
FOR
EYE
PAIN
OR
VISION
LOSS



1. INSPECT
(HEENT)

2. PALPATE

3. EOMI
(H
PATTERN)

4. ACUITY(
COVER
ONE
EYE
AND
SEE
HOW
MANY
FINGERS
ARE
UP
DO
IT
TO
BOTH
SIDES)

5. CONFRONTATION(
LOOK
AT
MY
NOSE
TELL
ME
WHEN
YOU
SEE
MY
FINGERS
MOVE,
PT

SHOULD
SEE
FINGERS
MOVE
SAME
TIME
YOU
DO,
START
AT
BOTTOM
AND
MOVE
FINGERS
UP

THEN
DO
OTHER
SIDE)

6. CONVERGENCE
(MOVE
YOUR
FINGER
FROM
YOUR
NOSE
TO
THE
PATIENTS
NOSE)

7. PERRLA

8. OPTHALMASCOPE/FUNDOSCOPE(
LOOKING
FOR
OBSTRUCTION,
HEMORHAGE,

NEOVASCULIZATION,
EXUDATE
AND
MICROANEURYSIMS







FATIGUE

ASSOCIATED
SYMPTOMS:HPI,
RAMPPS,
DESCRIPTION,
SUDDEN
OR
GRADUAL,
ANY
PAIN,

DEPRESSION,SUICIDE,
GUILT,
CONCENTRATION,
INTEREST,
INSOMNIA,SLEEP
CYCLE
(FALLING,
STAYING,

EARLY
RISING),
SNORING,NAPS
NIGHTMARES,
DAYTIME
SLEEPINESS,
PAIN,
WEAKNESS,
NUMBNESS,

TINGLING,
DECREASED
SENSATIONS,
RASH,
HOT
COLD
INTOLERANCE,
SKIN
CHANGES,
HAIR
CHANGES,


ROS:
HEADACHE,
DIZZY,
INFECTIONS,
FEVER,
CHILLS,
NS,CP,
SOB,
COUGH,
OBGYN,
THYROID,
N,V,D,C,AB

PN,
CHANGES
IN
BOWEL,
CHANGES
IN
URINATION,
WEIGHT,
APPTITIE,
POLYURIA,
POLUPHAGIA,

POLYDYPSIA,
BLOOD
IN
STOOL,
JOB
PERFORMANCE
AND
BRUISES.



FATIGUE

DD:
CHOP
AT
CD
 
 
 
 WORK
UP
 
 
 PE:INSPECT/PALPATE

CHRONIC
FATIGUE
SYNDROME
 
 CBC,
TSHT4
URINETOX
 
 
 HEENT

HYPOTHYROID
 
 
 
 BLOOD
GLUCOSE
 
 
 NECK/LN

OBSTRUCTIVE
SLEEP
APNEA
 
 HIV
ANTIBODIES
 
 
 CV/AUS

PTSD,
PANCREATIC
CANCER
 
 PPD
 
 
 
 
 PUL/AUS

ANXIETY,
ANEMIA
 
 
 NOCTOURNAL
PULSE
OXIMETRY
 ABD/A,P.PER

TB
 
 
 
 
 POLYSONOGRAPHY
 
 
 EXT:
INS,REF,
MOTO

COLON
CANCER

 
 
 COLONOSCOPY
WITH
BIOPSY/LI

 EDEMA,
BRUISES,PULSE

DEPRESSION,
DI,
DM
 
 
 AST/ALT/LIPASE/AMYLASE



HEADACHE

ASSOCIATED
SYMPTOMS:
HPI,
RAMPPS,DESCRIPTION,
SUDDEN
OR
GRADUAL,
UNILATERAL
OR

BILATERAL,
AURA,
HALOS,FLASHING
LIGHTS,
SPEECH,
EAR
PAIN,
RUNNY
NOSE,
SINUS
INFECTION,
SINUS

PAIN,
URI,
WEAK,
NUMB,
TINGLING,
DECREASED
SENSATION,
FATIGUE,
VISION
CHANGES,
RED
EYES,

BURNING
EYES,
ROS:JOINT
PAIN,
FATIGUE,
STRESS,
AB
PAIN,
FEVER,
NECK
PAIN,JAW
PAIN,
CP,
SOB,

COUGH,
N,V,
BOWEL
CHANGES,
URINARY
CHANGES,
DOES
HEADACHE
DISTRUB
SLEEP,
WEIGHT

APPETITE,
RE:
TO
FOOD,
RE:
TO
MENSES,
STRESS,
HEAD
TRAUMA.



HEADACHE

DD:
MC
HITTS
 
 
 
 
 WORK
UP
 
 PE:INSPECT/PALPATE

MIGRAINE,
MENINGITIS

 
 
 CBC,
ELYTES,ESR
 HEENT/MOUTH/NECK

CLUSTER
 
 
 
 
 CT
HEAD
 
 NEURO:
CN,MOT,REF

HEMORRHAGE
(SUB
ARACHNOID)
 
 MRI
BRAIN
 
 CV:
AUS

INTRACRANIAL
BLEED
(WORST
HA
EVER)
 LP
CS
FLUID
 
 PUL:
AUS

TENSION
 
 
 
 
 CT
SINUS
 
 NECK:
INSPECT/PALP

TRIGEMINAL
NEURALGIA
 
 
 
 
 
 EYES:
FUNDO

SINUSITIS
 
 
 
 
 
 
 



INSOMNIA

ASSOCIATED
SYMPTOMS:
HPI,
RAMPPS,DESCRIPTION,
SUDDEN
OR
GRADUAL,
ANY
PAIN,
ANY

DIZZINESS,
HEADACHE,
SLEEP
CYCLE,
FALLING,
STAYING,
EARLYRISING,
MULTIPLE
AWAKENINGS,

SNORING,
NAPS,
DAYTIME
FATIGUE,
STRES,
DEPRESSION,
CAFFEINE
INTAKE,
ACTIVITIES
BEFORE

BEDTIME,
NIGHTMARES.
ROS:
WEIGHT,
APPETITE,
HOT
COLD
INOLERANCE,
SKIN
HAIR
CHANGES,

PALPITAIONS,
HEART
RACING,
CP,
SOB,
COUGH,
INFECTIONS,
OBGYN,
N,V,D,C,
ABPN,
BOWEL
CHANGES,

URINARY
CHANGES.





INSOMNIA

DD:
CS
CHIPS
 
 
 
 
 
 WORK
UP
 
 PE:INSPECT/PALPATE

CIRCADIAN
RHYTHM
DISORDER

 
 
 CBC/
URINE
TOX
 HEENT/INSPECT/PALP

STRESS
INDUCED
INSOMNIA
 
 
 
 TSH
 
 
 MME

CAFFEINE
INDUCED
INSOMNIA
 
 
 
 MME
 
 
 CV/PUL

HYPERTHYROID

 
 
 
 
 POLYSONOGRAPHY
 ABD

INSOMNIA
WITH
MAJOR
DEPRESSIVE
DISORDER

 BECKS
DEPRESSION
SCALE

PRIMARY
HYPERSOMNIA

SLEEP
APNEA
(OBSTRUCTIVE)



LOSS
OF
CONSCIOUSNESS

ASSOCIATED
SYMPTOMS:
HPI,
RAMPPS,
ANY
PAIN,DESCRIPTION,
SUDDEN
OR
GRADUAL,
WHAT

HAPPENED
BEFORE
YOU
PASSED
OUT(LIGHTS,
SPINNING
SENSATION,LIGHTHEADED,SWEATING,

PALIPITAIONS,
DIZZINESS,
SOB,
VISION
CHANGES,)
HOW
LONG
WERE
YOU
PASSED
OUT?
DID
ANYONE

SEE
YOU?
DURING
(BITE
TONGUE,
SHAKING
MOVEMENTS,
LOSS
BLADDER
CONTROL,
FOAMING
FROM

THE
MOUTH,
TRAUMA,
FALL,)
AWAKENING
(CONCENTRATION,
DIZZINESS,
CONFUSION,
SPEECH,
NUMB,

WEAK,
DECREASED
SENSTION,
SOB,
CP,
SHAKING/SEIZURE
MOVEMENTS/FOR
HOW
LONG,
WALKING,

HEADACHE,
PAIN.
ROS:
HEAD
TRAUMA,
INFECTIONS,
FEVER
CHILLS,
CP,
SOB,
OBGYN,

HOT/COLD/SKINHAIR
CHANGES,
N,V,D,C,
ABPN
BOWEL
CHANGES
URINARY
CHANGES,SLEEP
CYCLE,

TRAVEL,
WEIGHT,
APPETITE,
STRESS.



LOC

DD:
SACC
VD
 
 
 
 WORK
UP
 
 
 PE:INSPECT/PALPATE

SEIZURE
DISORDER
 
 
 CBC/URINE
TOX/E
LYTES
 HEAD/NECK/CAROTIDS

AORTIC
STENOSIS
 
 
 CXR
 
 
 
 MOUTH/THYROID

CONVULSIVE
SYNCOPE
 
 
 CT
HEAD
OR
MRI
BRAIN

 CV:PALP/AUS

CARDIAC
ARRYTHMIA
 
 
 ECG/HOLTER
MONITOR

 PUL:
AUS

VASOVAGAL
SYNCOPE
 
 
 ECHOCARDIOGRAM
 
 EXT:
PAL/PULSES

DRUG
INDUCED:

 
 
 PROLACTIN
LEVELS
 
 NEURO:MME,CN,MOT,REF

HYPOTENSION/SYNCOPE
 
 EEG
 
 
 
 SEN,CER,ROM,GAIT,FUNDO





NOSEBLEED

ASSOCIATED
SYMPTOMS:
HPI,RAMPPS,DESCRIPTION
OF
WHAT
YOU
ARE
EXPERIENCING,WHICH

SIDE,SUDDEN
OR
GRADUAL,
COLOR,
AMOUNT,
BLOOD,
CONSISTENCY
OR
DISCHARGE,
ODOR
AND

OTHER
DISCHARGE,
TRAUMA,
BRUISING,
NASAL
SURGERY,
SNEEZING,
BLOWING
NOSE,
POST
NASAL

DRIP,URI,
BLEED
WITH
DENTAL,
TYLENOL
USE,PAIN,
TREATMENT,
HOW
OFTEN.
ROS:
HEADACHE,
DIZZY,

INFECTIONS,
CP,
PALPITATIONS,
SOB,
OBGYN,
HOT/COLD,
SKINHAIR
CHANGES,
N,V,D,C,AB
PN
BOWEL

CHANGES,
URINARY
CHANGES,
FATIGUE,
WEIGTH,
APPETITE.



NOSEBLEED

DD:
HEATS
D
 
 
 
 WORK
UP
 
 
 PE:INSPECT/PALPATE

HEPATIC
ENCEPHALAPATHY
 
 CBC,INR,LYTES,GLUCOSE
 LOOK
IN
THE
NOSE

EPISTAXIS
FROM
LIVER
FAILURE

 AST/ALT
T.BILI.
 
 
 HEAD/NECK/EARS/EYES

ALCOHOLE
TOXICITY
 
 
 TYLENOL
LEVEL
 
 
 CV
 

TYLENOL
TOXICITY
 
 
 ETOH
LEVEL
 
 
 ABD

SUBDURAL
HEMATOMA

 
 CT
HEAD
 
 
 NEURO:MME,MOT,GAIT,EXT.

DRUG
ABUSE
 
 
 
 RUQ
U/S
 
 
 BRUISES/EXT
INSP/PAL

NUMBNESS
&WEAKNESS



ASSOCIATED
SYMPTOMS:
HPI,
RAMPPS,DESCRIPTION,
ANY
PAIN,
SUDDEN
OR
GRADUAL,
UNILATERAL

OR
BILATERAL,
HEADACHE,
NECK
PAIN,
BACK
PAIN,
SPEECH,
WALKING,
CONCENTRATION,
SEEING,

HEARING,
WEAKNESS,
NUMB,
TINGLING,
DECREASED
OR
INCREASED
SENSATION,
STRENGTH,
HISTORY

OF
A
STROKE,
DIZZY,SEIZURES,URI,
POLYURIA,
POLYPHAGIA,
POLYDIPSIA.ROS:
NEURO,
INFECTIONS,
CP,

PALPITATIONS,
SOB,
OBGYN,N,V,D,C,AB
PN,
BOWEL
CHANGES,
URINARY
CHANGES,WEIGHT,
APPETITE,

TRAVEL.



NUMBNESS
AND
WEAKNESS

DD:
MISSD
BATH
 
 
 
 WORK
UP
 
 
 PE:INSPECT/PALPATE

MULTIPLE
SCLEROSIS
 
 
 
 CBC/GLUCOSE
 
 
 HEENT/NECK

INTRACRANIAL
TUMOR
 
 
 
 BUN
CR/INR
 
 
 NEURO:
MME,CN

SEIZURE
 
 
 
 
 CT
HEAD
 
 
 MOTOR,REF,SENSA

STROKE

 
 
 
 
 SERUM
B12

 
 
 CER,GAIT

DIABETIC
PERIPHERAL
NEUROPATHY
 
 XRAY
OF
(AREA)

 
 MSK:
PULSE,MOTOR

B12
VITAMIN
DEFICIENCY
 
 
 DOPPLERU/S
CAROTIDS

 ROM,INSPE,PALPA

ALCOHOLIC
PERIPHERAL
NEUROPATHY
 
 ECG
 
 
 
 

TIA
 
 
 
 
 
 CXR

HYPOGLYCEMIA





PSYCHIATRIC
CASES:



HALLUCINATIONS/DEPRESSION/AND
PSYCHE
CASES:


ASSOCIATED
SYMPTOMS:
HPI,RAMPPS,DESCRIPTION,
WHAT
HAPPENED,WHATS
HAPPENS
BEFORE,

DURING
AND
AFTER
THE
HALLUCINATION,
SUDDEN
OR
GRADUAL,
HOW
LONG,
OTHER
HALLUCIANTIONS

OF
SMELL,
BUGS,
VOICES,
VISUAL,
WHEN
DID
IT
FIRST
HAPPEN,
WHAT
WERE
YOU
DOING,
WAS
THIS
THE

FIRST
TIME,
DO
YOU
KNOW
WHAT
CAUSED
IT,
DID
SOMEHTING
SPECIFIC
HAPPEN
BEFORE
THE

INCIDENT,
WHAT
TIME
OF
THE
DAY
IS
IT
THE
WORST,
FEVER,
VOMIT,
DAILY
ACTIVITIES,

JOBINTERFERENCE,
CONCENTRATIONS,
SLEEP
PATTERN,
RE:
TO
SLEEP,
MEMEORY,
DEPRESSED,

RESTLESS,
AGITATED,
SUICIDE,
HOMOCIDE,
ELATED,
GUILT,
DO
FEEL
OTHERS
WANT
TO
CONTROL
YOU,

STRESS,
PTSD,
LEGAL,
FAMILY
RELATIONSHIP,
HEADACHE,
MIGRAINS,
SPEECH.
ROS:
TRAUMA,
LOC,

CHEST
PAIN,
AB
PAIN
URINARY
CHANGES,
BOWEL
CHANGES,
WEAKNESS,
SHAKING
MOVEMENTS,

INFECTIONS,
OBGYN,
WEIGHT,
APPETITE,
HOT,COLD
SKIN
HAIR,

MOOD
,
INTEREST,
HOBBIES,
CRYING,

FATIGUE,
INSOMNIA,
HIGH
OR
LOW
ENERGY,
RACING
THOUGHTS,
CAFFEINE
INTAKE

PMH:
DM,
HTN,
MENTAL
ILLNESS,
HIV,
HIGH
CHOLESTEROL,






HALLUCINATIONS/PSYCH

DD:
PSYCH
BASHED
 
 
 WORK
UP
 
 
 PE

ND
PSYCHOSIS
2 
TO
DRUG
ABUSE

 MME
 
 
 
 MME
FULL

BIPOLAR
WITH
PSYCHOSIS
 
 CBC/URINE
TOX/BMP
 
 HEENT/INSP/PAL

ALCOHOLE
WITHDRAWL
 
 SERUM
ETOH
LEVELS
 
 NECK:PALP

SCHIZOPHRENIA
 
 
 TSH
 
 
 
 NEURO:
CN,
MOT,REF

HYPERTHYROID

 
 
 CT/MRI
BRAIN/EEG
 
 SENSAT,ROM,GAIT

ETOH
INTOX
 
 
 
 
 
 
 
 
 CARDIO

DEPRESSION
WITH
PSYCHOTIC
FEATURES

DEPRESSION:

DD:
A
BB
C
D’S
OF
DEPRESSION

 WORK
UP

ADJUSTMENT
DISORDER
 
 PHYSICAL
EXAM

BEREAVMENT
 
 
 
 MME/BECKS
DEPRESSION
SCALE

BIPOLAR
1
DISORDER
 
 
 TSH

CYCLOTHYMIC
DISORDER
 
 CBC/ETOH
LEVELS/BMP

DYSTHYMIC
DISORDER
 
 
 URINE
TOX

SCHIZOAFFECTIVE
DISORDER
 
 CT/MRI
BRAIN/EEG





PATIENT
NOTE
FOR
PSYCHE
CASES:

HPI

ROS

ALLERGIES

MEDICATIONS

PMH

PSH

FH

SH



PHYSICAL
EXAM
PATIENT
NOTE
IF
NO
PHYSICAL
EXAM
PSYCH
HISTORY
GOES
HERE
IF
THERE
IS
A
PE

PSYCH
HISTORY
GOES
WITH
HPI

GA

VS

PSYCHIATRIC
HISTORY

ALERT
ORIENTED
TO
PERSON
PLACE
AND
TIME

SPEECH:
RAPID,
SLOW,
SLURRED,
QUIET

MEMORY:
REPEAT‐
3
WORDS

ATTENTION
AND
CONCENTRATION:
SAY
WORLD
BACKWARDS

COOPERATIVE,
NONCOOPERATIVE,


COMMANDS:
CLSOE
AND
OPEN
EYES

LANGUAGE:

REPEAT‐NO
IF
AND
OR
BUTS

MOOD:
ELATED
OR
DEPRESSED

AFFECT:
AGITATED,
DEPRESSED,
TIRED,
WEAK

THOUGHT
PROCESS:
HALLUCINATIONS,
HEARING
VOICES,
DELUSION,
DEPRESSED,
SUICIDAL

INTENT:
SUICIDAL,
HOMICIDAL





TREMOR

ASSOCIATED
SYMPTOMS:
HPI,RAMPPS,DESCRIPTION,
SUDDEN
OR
GRADUAL,
PAIN
IN
THE
JOINT,

CAFFEIN
USE,
SKIN
OR
HAIR
CHANGES,
HOT
OR
COLD
INTOLERANCE,
RASH,
TRAUMA,
HEADACHE,

CONFUSION,
PALPITATIONS,
WEAKNESS,
NUMBNESS,
TINGLING,
INCREASE
OR
DECREASE
OF

SENSATION,
WALKING,
TALKING,
DROOLING,
HANDWRITING,
DEATH
SHAFT,DEPRESSION,
FEVER,

COUGH,
SOB.
ROS:
HEADACHE,
LIGHTHEADED,
INFECTION,
CP,
PALPITATIONS,
SOB,
OBGYN,
THYROID,

N,V,D,C,
ABPN
BOWEL
CHANGES,
URINARY
CHANGES,
SLEEP
DISTURBANCES,
TRAUMA,
WEIGHT,

APPETITE,
SUPPORT
SYSTEM





TREMOR

DD:
MD
WHEPP
 
 WORK
UP
 
 
 PE:INSPECT/PALPATE

MIDBRAIN
LESION
 
 CBC/URINE
TOX/TSH
 
 LOOK
AT
THE
LIMB
WITH

DRUG
INDUCED
TREMOR
 AST/ALT/T.BILIRUBIN
 
 THE
TREMOR
AND
COMPARE

WILSONS
DISEASE
 
 MRI
BRAIN
 
 
 MOTO,ROM,REF,
SENS
OF


HYPERTHYROID

 
 CERULOPLASMIN
 
 THE
LIMB
WITH
THE
TREMOR

ESSENTIAL
TREMOR
 
 SLIT
LAMP
EXAM
 
 CV/PUL/

PARKINSONS
DS
 
 
 
 
 
 NEURO:
MME,
CN,
MOTOR,SEN,REF

PHYSIOLOGICAL
TREMOR
 
 
 
 
 CER,GAIT