ASSOCIATED SYMPTOMS NEURO

Description and sudden or gradual

liq ondpftc c/i rad agg all associated ramp his foss. Nic gus wadesst

MME: concentration/ memory loss and confusion: description of what you are
forgetting, death shaft, w, n,t,s, walking, talking, seizures, shaking, speech, vision,
fainting, falls, lightheaded, fatigue, clumsiness, dizzy, weight, appetite, hot, cold,

Psyche: description, sudden or gradual hallucinations (audio, visual, tactile, odor, taste)
speech, caffeine, homicidal, suicidal, if so what’s your plan, pain, loc, concentration, hot,
cold, weight, depression, stress, mood, racing thoughts, headache, /DEPRESSION ADD
THESE: trauma, energy level, prior episodes, fatigue, insomnia, sleep cycle, pain,
crying.

NOTE THE PATIENT NOTE FOR PSYCHE CASES ARE WRITTEN DIFFERENT
THAN THE OTHER CASES.

Head ache: location, halos, speech, auras, fatigue, vision, eye pain, ear pain, jaw pain,
neck pain, stress, weight, appetite, joint pain, fever, rash, sinuses, Uri, runny nose,

Eye changes: discharge, vision, glasses/contacts/ blurry/unilateral or bilateral, halos,

cloudy, night-vision, dryness, pain with light, swelling, lid lag or swell, lesions,

Physical exam: inspect, palpate, eomi, acuity, confrontation, convergence, perrla,

fundoscope

Ear changes: (dizzy, hearing loss or ear pain) pain, location, position, ringing, spinning,
headache, air travel, Uri, fever, falls, pressure, discharge, balance, loud noises, infections,
w, nu, t, n, v, runny nose, sore throat, cough, trauma, stool, ab pain

Work up: ct head, audiometry, tympanography, brainstem audiometry, vdrl/rpr

Nose: bleed: trauma, bruising, nasal surgery, location, sneezing, blowing nose, post nasal
drip, uri, easy bleed, Tylenol, pain, treatment tried, or breathe from nose
Bleed or discharge
Cabcod
Color
Amount
Blood
Consistency
Odor
Discharge
Throat: swallow food or liq or pain see dysphagia in abdominal section or sore-throat in
respiratory section

Numbness: location and neuro associated w/ msk for pain

Weakness: ‘’ ‘’
Tingling
Tremor

Fainting
Falls/ clumsiness

Fatigue: STRESS, DEPRESSION, SUCIDE, GUILT, CONCENTRATION, SLEEP

CYCLE QUESTIONS, SNORE, NAPS, NIGHTMARES, DAYTIME TIREDNESS,
HOT COLD Intolerance, skin, hair, weight appetite, chest pain, sob, cough, fever, chills,
gi, gu, poly uria, phagia, dypsia, ill contacts and nightsweats.

Physical exam: heent, neck, cv, pul, ext for edema, reflexs, and motor

Work up: cbc, urine tox, tsh t4, bld glucose, nocturnal pulse oxometry, polysonography,
ast, alt, lipase amylase, colonscopy

Shaking: tremor, caffeine, rash, ha, confusion, drooling, writing, walking, dep, f,
cough, sob,
Sensation
Strength
Seeing:
Seizures: (loc) BEFORE: sweating, palpitations, sob, visual changes, dizzy. DURING:
biting tongue, incontinence, and any movements. AFTER: confusion, concentration,
speech, walking, n, w, and sob. Trauma, falls, w, n, t, s, talking, walking, seeing,
headache or any pain.

Stroke
Standing
Sitting
Speech

Sleep: insomnia, description, sudden or gradual, sleep cycle, snoring, naps, daytime
fatigue, depression, caffeine, anxiety

Physical exam: mme, cv, pul, ab

Walking
Talking
Hearing

Pain: head, neck, back arms legs

Poly uria, phagia, dypsia

Weight, appetite hot or cold

ACTIVITIES OF DAILY LIVING (ADL) CASE

DEATH

D: DRESSING
E: EATING
A: AMBULATION
T: TOILETING
H: HYGIENE (OBSERVE FOR HYGIENE OF THE PATIENT)

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) : SHAFT CASE

S: SHOPPING
H: HOUSE KEEPING
A: ACCOUNTING (MANAGING THE BILLS)
F FOOD PREPARATION
T: TRANSPORTATION

Physical exam
1. heent
2. mme
3. cn
4. motor
5. reflex
6. sensation
7. cerebellum
8. gait
9. cv, carotis, pulses
10. pul
11. abd
12. extremeties

Work up: cbc with diff, ct head, serum b12, mri brain, esr, tsh, blood glucose, urine tox,
slit lamp, lp csf and eeg