Name @NAME@ MRN @MRN@ DOB @DOB@ Date of service @TD@ Primary Care Physician:@PCP@
SUMMARY OF RECENT HOSPITALIZATION:
CURRENT CLINIC VISIT:
REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies headache. EYES: Denies double or blurred vision. ENT: Denies dysphagia CV: Denies palpitations. RESPIRATORY: Denies shortness of breath. GI: Denies melena or nausea/vomiting. GU: Denies hematuria. MSK: Denies joint pain SKIN: Denies unexplained bruising. NEURO: Denies numbness, tingling, or weakness. Denies speech problems. Denies gait disturbances. Denies memory problems or confusion. Denies dizziness. PSYCH: Denies anxiety.
PAST MEDICAL HISTORY: @PMH1@ @SURGICALHX@ @ALLERGY@ @CMEDBRIEF@ @SOC@ @FAMHX@
VITAL SIGNS: @V@
PHYSICAL EXAM: General : Alert, cooperative, no distress, appears stated age, normal mood/affect HEENT: Normocephalic,without obvious abnormality, atraumatic PERRLA, conjunctiva/corneas clear, EOM's intact Neck: Supple, symmetrical, trachea midline. Lungs: Respirations unlabored
Abdomen: Non-obese. Extremities: Warm and well perfused. No lower extremity edema. Normal development b/l Heart: ***
Neurological Exam: Mental Status: Alert. Oriented to person, place, and time. Recent and remote memory intact. Follows commands. Normal attention and concentration. Speech is non-dysarthric. Language is fluent. No evidence of neglect on double simultaneous stimulation. CN: II: Normal visual fields b/l when testing with unilateral stimulation in each of the four quadrants individually. Pupils 3 mm b/l constricting with appropriate accomodation III, IV,VI: Extra-ocular movements are intact in all directions of gaze with convergence. PERRLA. No nystagmus. No ptosis. V: Normal facial sensation in the V1,V2 and V3 trigem. facial distribution VII: Facial symmetry with normal lip seal and eye closure. VIII: Bilateral hearing intact to voice. IX,X: Uvula in midline. Palate elevates symmetrically. Voice not hoarse. XI: Shoulder shrug intact bilateral XII: Tongue in midline on protrusion STRENGTH: 5/5 to bilateral upper extremities (deltoid, triceps, biceps, wrist flexion/extension, and interossei). There is no drift BUE. FFM intact. 5/5 to bilateral lower extremities (Iliopsoas, quadriceps, hamstrings, and plantar/dorsiflexion). There is no drift BLE. TONE: There is no increased tone, cogwheel rigidity, or fasciculations present. SENSATION: Symmetric and intact to light touch. REFLEXES: 2+ to bilateral UE/LE Bilateral plantar reflexes downgoing. COORDINATION: Bilateral finger to nose intact without evidence of ataxia. GAIT/STANCE: Patient has a normal walk with good arm swing.
REVIEW OF DIAGNOSTIC DATA: @LASTLABX(HDL)@ @LASTLABX(CALCLDL)@ @LASTLABX(CHOLESTEROL)@ @LASTLABX(TRIGLYCERIDE)@ @LASTLABX(HGBA1C)@ @LASTLABX(INR)@
PATIENT EDUCATION/PERSONAL RISK FACTOR REVIEW: ? Discussed patient specific blood pressure control *** ? <150/90: general population (no history of DM or CKD) and age greater than 60 years old ? <140/90: general population (no history of DM or CKD) and age less than 60 years old ? <140/90: any patient with history of diabetes mellitus or CKD ? Discussed most recent cholesterol values- LDL: @LASTLABX(CALCLDL)@ ? Discussed most recent HgA1C- @LASTLABX(HGBA1C)@ ? Reviewed Diet: follow a low fat, low salt, diabetic diet ? Exercise recommendations reviewed: Increase cardiovascular exercise to 3-5 times per week, for 30 plus minutes unless contraindicated ? Discussed signs and symptoms of an acute stroke and to call 911 immediately if experienced. BEFAST reviewed and patient verbalized understanding.
Type of stroke -Etiology: -Current symptoms: -Dates of recent hospitalization: -Antiplatelets: -Statin therapy: Goal LDL < 70 for secondary stroke prevention. Continue on *** -Last documented NIHSS: -Current NIHSS: -Last documented MRS: -Current MRS: -Risk factor modification -Follow-up Diagnostics: -Follow-up in Clinic: -Additional Orders: