SIEZURE

HISTORY_LIST
onset
duration
description of seizure
aura
pallor
incontinence of urine
incontinence of feces
salivation
vomiting
aspiration
post-ictral weakness
post-ictal paralysis
visual changes
paresthesias
lethargy
disorientation
somnolence
stiff neck
lipsmacking
leg movement
teeth clenching
INFECTIOUS DISEASES
sinusitis
CHRONIC DISEASES OR DISORDERS
past seizures
TIA's
stroke
migraine headaches
diabetes hypertension
hypocalcemia
hypoglycemia
hypomagnesemia
vasculitis
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal

MEDS_LAB_TESTS
**** MEDS
meperidine overdose
high dose penicillin
phenothiazines
lithium
lidocaine
anticholinergics
antihistamines
antidepressants
salicylates
amphetamines
insulin
oral hypoglycemics
theophylline
propranolol
isoniazid
PCP
carbon monoxide
lead ingestion
pesticides
**** LAB
serum alcohol
anticonvulsant levels
Electrolytes
BUN
creatnine
glucose
calcium
magnesium
CBC
LFT
UA
urine toxicology
**** TESTS
EEG
MRI/CT scan
lumbar puncture
RPR/VDRL

REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

REVIEW_OF_SYSTEMS_3
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty in fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
psychiatric hospitalizations 
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia

PHYSICAL_EVAL_1
VITALS
BP
Pulse
Temp
GENERAL
lethargy
SKIN
cafe-au-lait
neurofibromas
splinter hemorrhages
unilateral port-wine facial nevus
facial angiofibromas
hypopigmented ash leaf spots
shareen patches
periungual
fibromas
spider angiomas
malar rash
needle marks
HEENT
pigmented iris hamartomas
head trauma
PERRLA
nystagmus
EOMI visual fields
papilledema
venous pulsations
gum hyperplasia
tongue lacerations
buccal lacerations
temporal bruits
carotid bruits
neck rigidity

PHYSICAL_EVAL_2
CHEST
rhonchi
crackles
wheezes
HEART
regular rate & rhythm
murmur
S3
GU
incontinence of urine
incontinence of feces
RECTAL
guaiac (occult blood)
EXTREMITIES
cyanosis
bone pain
fractures
NEURO
dysarthria
able to follow commands
sensory
weakness
pinprick
coordination
cranial nerves
Babinski's sign
Rhomberg's sign

DIFF_DIAGNOSIS
Noncompliance with anticonvulsants
hypoglycemia
hyponatremia
hypocalcemia
hypomagnesemia
hypertensive encephalopathy
alcohol/barbiturate withdrawal
meningitis
encephalitis
uremia
pyridoxine deficiency
osmolar disturbances
trauma
arterivenous malformation
brain tumor
genetic disorder
congenital malformation
cerebrovascualr disease
stroke
hepatic failure
uremia
vasculitis
pseudoseizure


