Transcription of cardiology progress note - History and Physical
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cardiology progress note - History and Physical
Risk Factors:1. Male2. Male > 45 yoFemale > 55 yo3. Tobacco4.+ FHx Male <55 MI Female <65MI5. Cholesterol6. ObesityRisk Equivalent:1. DM2. CVA/Carotid Dx3. Previous MI4. AAA5. PADMeds:RF:RE:PE:VS:All:Include ranges for BP, HR,Resp, Sat, Tm and progress Note GuidelinesCC:HPI:Tele:TRS:PMH:SHx:FHx:So c:One line. Chest Pain or SOB or DOE What does EKG or tele monitor show? NSR? Arrythmias?Timi Risk Score (see side box)Just about the heart. Ex: Chest pain Quality (dull, sharp?), Duration, Quantity # of episodes) Radiation, Alleviating, Worsening. Plueritic? Positional?
Risk Factors: 1. Male 2. Male > 45 yo Female > 55 yo 3. Tobacco 4.+ FHx Male <55 MI Female <65MI 5. Cholesterol 6. Obesity Risk Equivalent: 1. DM 2. CVA/Carotid Dx
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