Documentos de Académico
Documentos de Profesional
Documentos de Cultura
CHIEF COMPLAINTS
HPI
SYMPTOM LIST
•Dyspnea
•Tachypnea
•Orthopnea
•Tachycardia
•Hypertension
•Thoracic oppression
•Cold extremities with cyanosis or not
•Cough
o Frothy /Pink sputum
•Extensive use of accessory muscles of respiration
•Moist rales
o With / without wheezing
SEVERITY
• Mild
• Moderate
• Severe
• Absent
• Normal
• Increased
• Decreased
• Stable
• No significant change from prior visit
HISTORY (PMFSH)
•Mitral stenosis
•Atrial myxoma
•Thrombosis of a prosthetic valve
•Cor triatriatum
•Rheumatic fever
•Congestive heart failure (CHF)
•Cardiomyopathy
•Acute MI or ischemia
•LV diastolic dysfunction
•Nonischemic acute mitral regurgitation
•Aortic regurgitation
•Endocarditis
•Aortic dissection
•Constrictive pericarditis
•Pericardial tamponade
•Myocardial contusion
•Hemodialysis-dependent renal failure
•Aortic stenosis
•Hypertrophic cardiomyopathy
•Hypertension
FAMILY HISTORY
•Hypertension
•Cardiac diseases
•Diabetes
•Renal disorders
ALLERGIES
Drugs____
Environment
SOCIAL HISTORY
Habits
•Alcohol
•Tobacco
•Drugs
Occupation___
ROS
PHYSICAL EXAMINATION
TESTS TO BE ORDERED
•Blood tests
o CBC with differential count
o Electrolytes
o Serum Creatinine
o Blood Urea
o Liver enzymes
o C-reactive protein
o Complete blood count
o PT
o aPTT
o B-type natriuretic peptide (BNP)
o BUN
o Serum protein concentration
•Urinalysis and microscopic examination of urine
•Room air arterial blood gas concentrations
o PO2 and PCO2
•Chest X-ray films: PA and Lateral
•ECG:
•Right heart catheterization
•2D-echo
•Transesophageal echocardiography (TEE)
•Blood cultures
•Pulmonary function tests
•Other Tests
o Arterial blood gas analysis
o Pulse oximetry
o NT-proBNP test
o BNP test
ASSESSMENT/PLAN: INSTRUCTIONS/EDUCATION
Patient Education
MEDICATION
o Nitroglycerin
o Furosemide
o Bumetanide
o Ethacrynic acid
o Torsemide
o Nitroprusside
o Dobutamine
o Dopamine
o Norepinephrine
o Milrinone
o Enalapril
o Ramipril
o Quinapril
o Perindopril
o Lisinopril
o Benazepril
o Captopril
o Morfine
o Naloxone
o Digoxin
o Inhaled beta-adrenergic agonists / Aminophylin IV
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