SOCIAL Hx: [textarea rows="1" default="Patient denies tobacco, EtOH, and Drug use"] Review of System [textarea rows="20" default="\nConstitutional: No fever, No chills, No sweats, No weakness.\nEye: No recent visual problem, No icterus, No discharge.\nRespiratory: No shortness of breath, No cough, No cyanosis.\nCardiovascular: No chest pain, No palpitations, No bradycardia.\nGastrointestinal: No nausea, No vomiting, No diarrhea.\nGenitourinary: No dysuria, No hematuria.\nIntegumentary: No ecchymosis, no rash, no ulcers, edema, no dryness\nAllergic/Imm: No seasonal allergies, no hay fever, no itching, no frequent infections.\nHematologic/Lymphatic: No easy bleeding or bruising, No anemia, no swollen glands\nEndocrine: No heat/cool Intolerance, No Hair Loss, No excessive hair growth.\nMusculoskeletal: No back pain, No neck pain, No decreased range of motion.\nNeurologic: No headache, No confusion, No numbness. No seizures.\nPsychiatric: No agitation, no anxiety, no depression, no hallucinations."] PHYSICAL EXAMINATION [textarea rows="10" default="General: awake and alert. Head: atraumatic.\nEars: No drainage, Mouth: Oral mucuse is pink and moist.\nEyes: No drainage or hemorrhage. Optic disks sharp.\nCardiovascular: no bruits, heart S1 S2 regular.\nLungs: clear to ausculation.\nAbdomen: soft, nontender without guarding.\nExtremities: Peripheral pulses are present and normal."] Mental Status Orientation: AAO x [select value="3|0|1|2|3|4|"]. speech is [select value="normal rate and volume||pressured|monotonous|quiet|emotional|loud|forgetful|whispering|yelling|accented|impoverished|neologisms|aphasia|global aphasia|Broca's aphasia|Wernicke's aphasia|dysarthia|preservation|sterotypy|Hypoechoic"] [select value=" |clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"] Attention span and concentration:[select value="appropriate|intact|Abnormalitis Present|Pending|Cannot Be Assessed at this current moment|normal attention, concentration, intact ability to recall recent and remote information, normal abstraction|-"]. Immediate and remote memory:[select value="Intact and appropriate|Impaired Immediate|Impaired recent|Impaired remote|Intact Immediate|Intact recent|Intact remote|Partially Cooperative|Unable to assess"] Cognition/Memory - overall functioning: [select value="within normal limits|grossly intact|below average|above average|short-term memory loss|long-term memory loss|amnesia|anterograde amnesia|retrograde amnesia| history of head trauma|transient global amnesia"]. Fund of knowledge:[select value="appropriate|inappropriate"] Language:[select value="appropriate|inappropriate"][select value=" |within normal limits|responds only to questions|scant|mute|verbose|repetitive"]. [textarea rows="20" name="variable_1" default="Cranial Nerves (CN)\nCN II: visual fields were full to finger waving. \nCN III,IV,VI: eye movements were full. Pupils were equal, round, and reacted from 3 mm to 2 mm to light.\nCN VIII: hearing was grossly normal.\nCN IX,XII: palate elevation and tongue movements were symmetrical."] Motor (including CN VII, XI): [select value="There was no facial droop or flattening of the nasolabial fold, the shoulder shrug was symmetric, and there was no pronator drift.||"][textarea rows="1"] Motor: [select value="Grossly normal ROM in all four extremities |none|grimaces|tics|twitches|foot tapping|rocking back and forth|hand wringing|ritualistic behavior|mannerisms|posturing|nail biting|chewing movements|echopraxia|tardive dyskinesia|catatonic|unknown"]. Muscle tone and bulk: [textarea rows="2" default="normal in all four extremities and there was no spasticity, rigidity, or cogwheeling.2+ in the uppers and lowers. 2+ in the uppers and lowers. Plantar reflexes were flexor."] Reflexes: [textarea rows="2" default="2+ in the uppers and lowers. Plantar reflexes were flexor."] Sensory:[textarea rows="2" default="light touch and cold was symmetric on the face (CN V), trunk, and extremities."] Proprioception was [select value="normal|weakened|abnormal|absent"]. normal. Coordination: [select value="There was no ataxia on finger/nose and heel/knee/shin tests.|normal/no problems|awkward|clumsy|agile|falling easily|needed assistance|bed ridden|uses wheelchair|uses walker|unknown"]. Gait:[select value="differed|normal|hyperactive|slow|retarded|agitated|hesitant|propulsive|shuffling|dancing|ataxic|uncoordinated|unknown"]. GCS [textarea rows="1"] [comment memo="Eye Opening Spontaneous (4) To sound (3) To pressure (2) None (1) Verbal Respones Orientated (5) Confused (4) Words (3) Sounds (2) None (1) Motor Response Obeys commands (6) Localise to pain(5) Normal flexion (4) Abnormal flexion(3) Extension (2) None (1) "] NIHSS[textarea rows="1"] MRS[textarea rows="1"] [comment memo="0 The patient has no residual symptoms. 1 The patient has no significant disability; able to carry out all pre-stroke activities. 2 The patient has slight disability; unable to carry out all pre-stroke activities but able to look after self without daily help. 3 The patient has moderate disability; requiring some external help but able to walk without the assistance of another individual. 4 The patient has moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual. 5 The patient has severe disability; bedridden, incontinent, requires continuous care. 6 The patient has expired (during the hospital stay or after discharge from the hospital). 7 Unable to contact patient/caregiver. 8 Modified Rankin Score not performed, OR unable to determine (UTD) from the medical record documentation."]
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