dizziness E: fv: wD()a()B()@()@() while sitting this afternoon 30 min ago (15:00) decreased after taking her antihypertensive

agent Location: Quality: dizziness and vertiginous sensation Quantity: intermittent, 10/30 mins/ 1 hour per attack Onset: sudden / grdual Precipitating factor: elevated blood pressure (170-180/120-130 mmHg) Exaggerating factor: moving or changing position Relieving factor: lying down and rest similar experience before Associated symptoms () loss of consciousness () ear pain or discharge, tinnitus: () headache: () brainstem signs: dysphagia, diplopia, dysarthria, dystaxia () acute limb weakness or numbness () dyspnea on exertion, shortness of breath () chest pain or tightness () fever or chills chest pain Location: retro-sternal area Radiation: left arm, back, neck and shoulder Pattern: needle-like/dull pain Duration: 10+ minutes Cold sweating: (-) Aggrevating factors: exercise Relieving factors: rest CAD risk factors () Age ( men > 45y/o, women > 55y/o) () Family history () Smoking () Hypertension () Dyslipidemia (high LDL, low HDL, high TC/HDL or LDL/HDL ratio) () Diabetes Mellitus () Sedentary lifestyle TIMI score () Age >65 years old () Documented prior coronary artery stenosisi >50% () 3 or more than 3 CAD risk factors () Use aspirin in the preceding 7 days () 2 or more angina events in the preceeding 24 hrs () ST-segment deviation > 0.05mv () Increased cardiac biomakers NPO with IV fluid supplement On NG tube with decompression bosmine gauze compression record I/O abdominal pain Location: Quality: moderate/severe, dull/cramping/sharp/colic/steady Quantity: intermittent/persistent Onset: sudden/gradual Precipitating factor Exaggerating factor/ Relieving factor

Associated symptoms: () abdominal fullness () no stool or flatus passsage () radiation to back () migration to RLQ () tarry or bloody stool () loss of appetite/ body weight loss: kg in months (10% decrease in 6 months) () tea-color urine/clay-color stool () hunger pain/ post-prandial pain () small caliber of stool GYN: LMP: , duration: , interval: PMP: () vaginal spotting/ abnoraml discharge () possibility of being pregnant () recent sexual intercourse surgical history: GI bleeding () abdominal pain () nausea/vomiting () recent use of anticoagulant or antiplatelets () cold sweating, dizziness previous history (liver cirrhosis/PUD/DU/EV/GV) Last meal: AGE () abdominal pain () nausea/vomiting: blood/gastric juice/bilous/food vomitus () diarrhea: watery/bloody/tarry stool/green/mucus () appetite () fever or chills () general malaise/ muscle soreness () raw food or seafood intake () similar symptoms among family/colleague/classamates () previous treatment: LMD/our ER () URI symptoms PHx: no medical history or surgical history allergy: no known allergy to drug or food URI () dry cough/ productive cough: scanty/white/yellow () sore throat/dysphagia () nasal discharge/nasal stiffness () fever or chills () general malaise/ muscle soreness () similar symptoms among family/colleague/classamates () nausea/vomiting: () previous treatment: LMD/ our ER () GI symptoms PHx: no medical history or surgical history allergy: no known allergy to drug or food UTI () pain or buring sensation while urination () frequency/ urgency/ hesistency () oliguria/ polyuria () nausea or vomiting

() flank pain () fever or chills () general malaise/ muscle soreness () recent sexual intercourse/ hotspring : () previous treatment: LMD/ our ER PHx: previous UTI/APN allergy: no known allergy to drug or food Allergy: () shortness of breath () cold sweating/dizziness () periorbital swelling () rash: start from, spread to () sensation of itching, redness () migrate to other site in 24 hours () external use of cream or ointment () fever or chills () similar experience before allergy: no known allergy to drug or food Alcoholism () kinds/ amount: () loss of consciousness () no vomiting or choking () history of head injury, wound: () acute weakness or numbness () talk, obey order () move limbs/ ambulation () not accessbile possibly to due alcohol intoxication: re-evaluate after two ho urs TOCC Travel history (Da): Occupation (b~B~BqB~BC]~): Contact history (v): Cluster (gD): LMP: , duration: , interval: () possibility of being pregnant nursing home resident or long-term bed-ridden() allergy: no known allergy to drug or food medical history: hypertension (), diabetes mellitus(), CAD s/p stent(), old stro ke(), old AMI(), peptic ulcer() current medication: surgical history: no last meal:

T: travel CvBDaJhizXWzJC O: occupation ~vBwHHAV~zA~BqB~(tC]~) CGcontact vizX JGN C: cluster O_gDgsEvCwTNAEJLCvLv~ SOB

onset: () dyspnea on exertion, shortness of breath () orthopnea/ paroxysmal nocturnal dyspnea () chest pain or tightness () fever or chills () productive cough, increased sputum formation () cyanotic change hypertension () headache () nasuea/vomiting () conscious disturbance () shortness of breath () oliguria epistaxsis head injury E: DD: mechanism: no headache, no dizziness, no nausea/vomiting, no ILOC past history: allergy: no known allergy to drug or food traffic accident PI: fall down from motorcycle about 20 minutes ago fall on left/right side, () helmet mechanism: no collision with other motor vehicle, ]Bua]I^ MI: t>10km/hr, ^>6m, XWL1m, Fy` no ILOC, no neck pain or back pain, no head injury, no abdominal pain, no chest pain or SOB smooth ambulation by him/herself wound: laceration/ abrasion low back pain DD: lowe back pain after weight lifting two hours ago mechanism: heavy lifting, aggravate when climb upstair/downstair able to walk, but felt pain while weight-bearing mild numbness over not aggravated by bending forward no urinary incontinence, no hot flush past history: no medical or surgical history, no current drug use allergy: no known allergy to drug or food

Location: Quality: Quantity: Onset Precipitating factor Exaggerating factor Relieving factor Associated symptoms

Knee () age 55 or over () isolated tenderness of the patella (no bone tenderness of the knee other than the patella) () tenderness at the head of the fibula () inability to flex to 90 degrees () inability to weight bear both immediately and in the casualty department (4 s teps - unable to transfer weight twice onto each lower limb regardless of limpin g) Ankle () pain in the malleolar zone plus () Bone tenderness along the distal 6 cm of the posterior edge of the tibia or t ip of the medial malleolus () Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus () An inability to bear weight both immediately and in the emergency department for four steps. Foot () pain in the midfoot zone plus () Bone tenderness at the base of the fifth metatarsal (for foot injuries) () Bone tenderness at the navicular bone (for foot injuries) () An inability to bear weight both immediately and in the emergency department for four steps. fHwg}vEAGtwE dizziness improved, walking smoothly no history of recent head injury or trauma improved after Keto/primperan injection suggest admission ->fHi H General Appearance: ill-looking Skin: normal skin turgor, color, no skin rash or jaundice Eye: pink conjunctivae, anicteric sclera, pupil(R/L): 3/3mm, light reflex(R/L): +/+ Throat: not injected, no oral ulcer, no tonsil enlargement or pus formation Neck: no palpable mass, no jugular vein engorgement, no bruits, Lymph Nodes: No LAPs Chest: clear breath sound, bilateral air entry, no wheezing, no rhonchi, no stri dor, no crackle. Heart: Regular heart beat, no audible murmur, Pulse: strong and symmetric Abdomen: soft, flat, diffuse/epigastric/periumbilical/lower abdominal tenderness , normoactive bowel sound, no rebound tenderness Extremities: no pitting edema, freely movable, no limitation of movement, intact distal pulsation Consciousness: alert and awake, attention: intact Language(verbal / comprehension/ naming): intact VA / VF: intact, Pupil size : 3/3 light reflex +/+ Muscle Power Deep Tendon Reflex O O 5 V V 5 2+ V V 2+

5 / \ 5 2+ / \ 2+ Hoffmann: - / - , Babinski sign: - / Sensory : grossly normal, FNF: no dysmetria E: DD: pain over left limb since one week ago mechanism: @geqW^AL no headache, no dizziness, no nausea/vomiting, no ILOC, no chest pain unable to move or walk, bed-ridden for one week past history: hypertension, DM, complete RBBB alcohol intake: no past history: no medical or surgical history, no current drug use allergy: no known allergy to drug or food consciousness: alert and awake, GCS: E4V5M6 General Appearance: fair-looking, consciousness: alert and awake Eye: pink conjunctivae, anicteric sclera, pupil(R/L): 3/3mm, light reflex(R/L): +/+ Skin: normal skin turgor, color, no skin rash or jaundice Chest: clear breath sound, bilateral air entry, RHB without murmur Abdomen: soft, flat, normoactive bowel sound, no tenderness, no rebound tenderne ss Extremities: freely movable, intact distal pulsation