Cardiovascular system

{Cardiovascular system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] bradycardia 
[-] syncope 
[-] pre-syncope

[-] chest pain on exertion
[-] chest pain at rest
[-] 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

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Diagnostic investigation results: 
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
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 cardiovascular history:
[-] myocardial infarction 
[-] angina 
[-] rheumatic fever 
[-] cardiac valve disease 
[-] atrial fibrillation 
[-] other arrhythmia 
[-] sudden cardiac arrest  
[-] stroke/transient ischaemic attack 
[-] syncope

Cardiovascular treatment history:
[-] coronary artery bypass grafts 
[-] angioplasty/stents 
[-] pacemaker 
[-] implanted defibrillator 
[-] valve surgery 
[-] other surgery 
[-] catheter ablation 
[-] cryoablation

MEDICATIONS
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

FAMILY HISTORY
[-] heart disease
[-] hypertension
[-] sudden cardiac death

[Vital signs]

Skin colour: 
Temp (deg.C): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%):

PHYSICAL EXAMINATION
Relevant examination findings: {abnormalities}
[-] 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: 
[+] 
[-]

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Problems and issues:
-

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
[-] 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:

Referrals:
-

Information and advice given:
-

Medication:
-

Medical devices:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Cardiovascular system

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