|
HPI
|
|
|
Onset
• • •
|
Course
• • •
|
|
Severity
|
Location of pain
• • •
|
|
Gradual onset. Moderate. No other sx. No CHI
|
Chronic pain. sx are similar to prior episodes.
|
|
Fever?
|
Additional notes
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Head AT/NC. Full Neuro Exam: Negative
|
NEURO:
• • •
|
|
Additional Neuro Findings
|
|
|
PE: Superficial
|
Head to toe exam + No photophobia (abd deferred)
|
|
Insert Macro Here
|
|
|
|
|
|
MDM
|
|
|
DDx: meningitis vs SAH vs migraine vs sinus infection
|
MDM Notes
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
Clinician Attestation
|
|
