CAD follow-up
Age: years old
Gender:
HISTORY:
Returns for a follow-up
Cardiac history reviewed: , , , , ,
Last visit was ago
Progress since last visit:
Current symptoms:
, , , ,
,
, over
Impact on daily activities:
Overall quality of life:
Cardiac rehabilitation program:
Diet: , , , ,
Physical activity:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
ECG:
Echocardiogram:
Stress test:
Coronary angiogram:
Medications:
, , , , , , ,
Adherence:
Use of rescue nitroglycerin:
Vaccinations:
Pneumococcal:
Influenza:
Covid:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
,
DDx: stable angina, unstable angina, myocardial infarction, coronary artery spasm, silent ischemia, atypical chest pain, pericarditis, aortic stenosis, hypertrophic cardiomyopathy, heart failure, arrhythmias, anemia, thyroid disease, pulmonary embolism, pulmonary hypertension, esophageal spasm, GERD, peptic ulcer disease, panic attack, musculoskeletal pain
PLAN:
Investigations:
- Blood work: , , , , , , ,
- Urinalysis
- ECG
- Stress test
- Echocardiogram
- Coronary angiogram
Treatments:
-
-
-
-
-
-
-
-
- Lifestyle counseling: sodium restriction, healthy diet, increase exercise, weight loss
- Smoking cessation
- Home blood pressure monitoring
- Immunizations: ,
Further care:
- Referral to cardiac rehabilitation program
- Referral to cardiologist
- Follow-up in
HISTORY: EXAM: ASSESSMENT: PLAN: