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
 
 MIDBRAIN
LESION
 
 DRUG
INDUCED
TREMOR
 WILSONS
DISEASE
 
 HYPERTHYROID

 
 ESSENTIAL
TREMOR
 
 PARKINSONS
DS
 
 PHYSIOLOGICAL
TREMOR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


WORK
UP
 
 CBC/URINE
TOX/TSH
 AST/ALT/T.BILIRUBIN
 MRI
BRAIN
 
 CERULOPLASMIN
 SLIT
LAMP
EXAM
 
 
 
 
 
 



 
 
 
 
 
 
 


PE:INSPECT/PALPATE
 LOOK
AT
THE
LIMB
WITH
 THE
TREMOR
AND
COMPARE
 MOTO,ROM,REF,
SENS
OF

 THE
LIMB
WITH
THE
TREMOR
 CV/PUL/
 NEURO:
MME,
CN,
MOTOR,SEN,REF
 CER,GAIT



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