Cardiovascular System

#Cardiovascular System

S: Subjective

Presenting Complaint:
(-) Bradycardia 
(-) Syncope 
(-) Pre-syncope

(-) Dyspnoea on exertion 
(-) Dyspnoea at rest 
(-) Orthopnoea 
(-) Paroxysmal nocturnal dyspnoea 
(-) Reduced exercise capacity 
(-) Intermittent claudication 
(-) Peripheral cyanosis 
(-) Foot/ankle oedema 
(-) Varicose veins

(-) Chills 
(-) Fever 
(-) Night sweats 
(-) Fatigue/malaise 
(-) Weakness

(-) Other/s ->

Symptom Development:
- Onset: 
- Variation: 
- Aggravating factors: 
- Relieving factors:

Cardiovascular Risk Factors:
(-) Family history of early onset ischaemic heart disease 
(-) Smoking history 
(-) Hypertension 
(-) Hyperlipidaemia 
(-) Diabetes mellitus/impaired glucose tolerance 
(-) Gout 
(-) Obstructive sleep apnoea 
(-) Obesity

Past Medical History:
(-) Myocardial infarction 
(-) Angina 
(-) Rheumatic fever 
(-) Cardiac valve disease 
(-) Atrial fibrillation 
(-) Other arrhythmia 
(-) Sudden cardiac arrest  
(-) Stroke/transient ischaemic attack 
(-) Syncope

Treatment History:
(-) Coronary artery bypass grafts 
(-) Angioplasty/stents 
(-) Pacemaker 
(-) Implanted defibrillator 
(-) Valve surgery 
(-) Other surgery 
(-) Catheter ablation 
(-) Cryoablation

Family History:
(-) Heart disease 
(-) Sudden cardiac death (SCD)

Current Medication:
(-) DHP: dihydropyridine calcium channel blocker 
(-) CCB: calcium channel blocker: non-dihydropyridine 
(-) ACEI: angiotensin converting enzyme inhibitor 
(-) ARB: angiotensin receptor blocker 
(-) Beta blocker 
(-) Statin 
(-) Loop diuretic 
(-) Thiazide diuretic 
(-) Nitrates 
(-) Antiplatelet therapy: (-) aspirin, (-) clopidogrel, (-) dipyridamole

O: Objective

Examination Findings: **abnormalities**
(-) Skin colour: 
(-) Heart rate (bpm): 
(-) Pulse: 
  (-) regular
  (-) irregular pulse: 
    (-) repeating pattern
    (-) irregularly irregular
    (-) extra or missed beats

(-) Blood pressure (mmHg): 
(-) Respiratory rate (/min): 
(-) SpO2 (%): 
(-) Temperature (deg. C):

(-) Radio-femoral delay (feature of aortic coarctation)
(-) Digital clubbing
(-) Displaced apex beat
(-) Chest deformity/asymmetry
(-) Chest scars
(-) Raised JVP (>3 cm above sternal angle at 45 deg.)
(-) Heart murmur/s:
  (-) midsystolic transmitted to carotids (AS)
  (-) early diastolic transmitted down left sternal edge (AI)
  (-) pansystolic transmitted to axilla (MI)
  (-) midsystolic (low pitch) with presystolic opening sound (MS)
(-) Pericardial friction rub

(-) Basal crepitation
(-) Ascites
(-) Hepatomegaly
(-) Ankle oedema

Bruits:
- Carotid: (-) right, (-) left
- Iliac: (-) right, (-) left

Peripheral pulses: *abnormalities*
- Dorsalis pedis: (-) right, (-) left
- Posterior tibial: (-) right, (-) left

Other Findings:

Investigation Results:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:
(-) Chest X-ray (CXR) 
(-) Ambulatory BP monitor
(-) Trans-thoracic echocardiography (TTE) 
(-) Resting ECG 
(-) Ambulatory ECG (holter monitor) 
(-) Exercise stress echo/ECG 
(-) Dobutamine stress echo 
(-) Radionuclide stress myocardial perfusion imaging (MPI) 
(-) Coronary artery calcium score (CACS) 
(-) Coronary CT angiography (CCTA) 
(-) Arterial Doppler studies; region -> 
(-) Other/s ->

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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Cardiovascular System

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