Professional Documents
Culture Documents
System
PCU-MJCN
Class 2011
HISTORY
Past Medical History
Past Surgical History
Allergies
Medications, OTC
Dietary Habits
Social History
Family History
Current Health
Chief Complaint
Onset
Location
Duration
Characteristics
Associated manifetations
Aggravating factors
Relieving factors
Clinical Manifestations
CHEST PAIN
Pressure Worsened by:
Burning Exertion
Heaviness Eating
Constriction Emotions
Cold
Relieved by:
Rest
Nitroglycerin
CHEST PAIN
Sharp, fleeting, vague Worsened by
Sudden onset Deep breathing
Coughing
Releived by
Pain pills
Spontaneously
PALPITATIONS
Rapid heart beats Ask about
thumping medications
Prior CHF
Anemia
SYNCOPE-loss of consciousness related to
decrease cerebral perfusion
Sudden onset Warning manifestations
Prodromal aura
Dysrhythmias
Palpitations
seizures Vision changes
Dizziness or weakness
Occurs with
Micturition
Defections exertion
Occurs with fear, smells, sights
Occurs with position changes
Alcohol or drug abuse
Volume depletion
History of depression
Residual neuroligic deficit
DYSPNEA
Sudden Chronic
Occurs with: Occurs with:
Fever Anxiety
Exposure to high altitude Depression
Acute pulmonary edema LVHF
Pnemothorax Pulmonary disease
Pulmonary emboli Pleural effusion
Airway obstruction Asthma
Obesity
Poor physical fitness
Psychosomatic conditions
DYSPNEA
Exertional Dyspnea - cardiac
Orthopnea - pulmonary
Paroxysmal nocturnal dyspnea - LVHF
FATIGUE
Weariness or exhaustion
Can accompany complaints of dyspnea
Other causes
Anemia
Anxiety
Chronic disease
Depression
Thyroid dysfunction
EDEMA
Unilateral Bilateral
Deep vein thrombosis Initial site
Cellulitis progression
Lymphatic blockage History of
ASK CHF
Recent surgery or bed rest Nephrotic syndrome
Injury Shortness of breath
Skin color changes cough
Fever / redness
History of cancer
PHYSICAL EXAMINATION
General Appearance and LOC
VITAL SIGNS
Head and Neck
Neck Vein Assessment – jugular pulses
Carotid Artery Assessment - bruit
Thorax
PHYSICAL EXAMINATION
Abdomen
Extremities
Skin color
Skin turgor
Temperature
Clubbing
Edema
DIAGNOSTIC TESTING
Noninvasive Testing Echocardiogram
ECG Radiographic Cardiac
Exercise Tests Tests
Upright Tilt-Table
Chest X-ray
Tests CT Angiography
MRI
MRA – gadolinium
PET
DIAGNOSTIC TESTING
Invasive Cardiac Tests
Transesophageal Echocardiography
Cardiac catheterization