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CHIEF COMPLAINT
• Fatigue
• Shortness of breath
• Edema
• Chest pain
• Exertional dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Abdominal discomfort
• Syncope
• Nocturnal angina
• Diaphoresis
• Palpitations
HPI
SYMPTOM LIST
• Fatigue
• Shortness of breath
• Edema
• Chest pain
• Exertional dyspnea
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Abdominal discomfort
• Syncope
• Nocturnal angina
• Diaphoresis
• Palpitations
SEVERITY
• Mild
• Moderate
• Severe
• Absent
• Normal
• Increased
• Decreased
• Stable
• No significant change from prior visit
HISTORY (PMFSH)
PAST HISTORY
FAMILY HISTORY
• Heart diseases
• Hypertension
• Diabetes
• Syphilis
• Connective tissue disorders
ALLERGY
• Drugs___
• Environment
SOCIAL HISTORY
Habits
•Alcohol
•Smoking
•Tobacco
•Drugs____
•Note
Occupation_____
ROS
PHYSICAL EXAMINATION
Heart exam
• Normal, RRR, no MRG
• Pulse
• Rate that was
o Tachycardic
o Bradycardic
• Rhythm was
o Regular
o Irregular
o Irregularly irregular
• Murmur
o Physiologic
o S-3
o S-4
o Mitral click
o Note
TESTS TO BE ORDERED
Blood tests
• CBC
• Prothrombin time (PT)
• activated partial thromboplastin time (aPPT)
• Myocardial muscle creatine kinase isoenzyme (CK-MB)
• Lactate dehydrogenase panel
• Isoenzymes
• Albumin levels
• Serum electrolyte tests
• Hb%
• Heamotocriet value
• FBS
• PLBS
• RBS
Urinalysis
o Macroscopic
Urine Appearance.
Urine Bilirubin
Urine Blood
Urine Casts
Urine Color
Urine Glucose
Urine Ketones
Urine pH
Urine Protein
Specific Gravity
Urine Urobilinogen
o Microscopic
Urine WBS/hpf
Urine RBC/hpf
Urine Casts
Urine Other
• ECG
• Treadmill stress test
• Echocardiography
• Chest x-ray
• Transesophageal echocardiography (TEE)
• Cine nuclear magnetic resonance (cine NMR)
• Doppler ultrasound
• Aortic angiography
• Left heart catheterization
• Nuclear MRI imaging
SURGICAL TREATMENT
MEDICATION
• Hydralazine
• Nitroprusside
• Nifedipine
• Prazosin
• Captopril
• Furosemide
• Propranolol
• Digoxin
• Benazepril
• Enalapril
• Fosinopril
• Lisinopril
• Perindopril
• Quinapril
• Ramipril
• Trandolapril
• Candesartan cilexetil
• Eprosartan
• Irbesartan
• Losartan potassium
• Olmesartan
• Telmisartan
• Valsartan
• Clonidine
• Doxazosin
FOLLOW-UP