Congestive Heart Failure

HISTORY_LIST
***** HISTORY OF PRESENT ILLNESS
duration of dyspnea
onset of dyspnea
paroxysmal nocturnal dy
spnea
orthopnea
edema
pillows needed for sleeping
doe
exercise tolerance
weight gain
severity of dyspnea
chest pain
pleuritic pain
cough
fever
chills
sputum
nausea
vomiting
diaphoresis
palpitations
nocturia
fatigue
syncope
***** HISTORY
CHRONIC DISEASE
SYSTEMIC DISORDERS
past MI
diabetes
hypertension
excessive salt intake
coronary artery disease
valvular disease
arrhythmia
Digoxin
diuretics
NSAIDS
calcium channel blockers
beta blockers
PREVIOUS TESTS
ECG
Stress test
Nuclear scan
Echocardiogram
SOCIAL HISTORY
Smoking
Cocaine use
FAMILY HISTORY
CAD
heart failure
hypercholesterolemia
HTN

MEDS_LAB_TESTS
**** MEDS
***** LAB
electrolytes
BUN
CBC
CPK
MB
LDH
***** TESTS
ECG
CXR

REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
VITALS
BP
Postural BP
Pulse
Temp
Heart rate
GENERAL
Respiratory distress
Anxiety
NECK
JVD at 45(,carotid pulse 
  amplitude carotid pulse 
  duration,carotid bruits

REVIEW_OF_SYSTEMS_3
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

PHYSICAL_EVAL_1
CHEST
breath sounds
crackles
wheezes
rhonchi
dullness to percussion
unilateral hyperresonance
HEART
displaced PMI
parasternal apical heave
atrial fibrillation
rubs
decreased intensity of S1
paradoxical splitting of S2
presence of S3  gallop
presence of S4
holosystolic apex murmur
dyskinetic cardiac impulse
enlarged apical impulse
prolonged apical impulse
displaced apical impulse
Levine's sign (patient with
  clenched fist over sternum)
ABDOMEN
hepatojugular reflex
ascites
hepatomegaly
liver tenderness
abdominal distention
EXTREMITIES
pitting edema
non-pitting edema
extent of edema
pulses
cyanosis
clubbing

PHYSICAL_EVAL_2
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty: fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
hospitalization for, 
   psychiatric problems
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia

DIFF_DIAGNOSIS
Heart failure
MI
PE
Constrictive pericarditis
Pleurisy
Cardiomyopathy
Valvular Dz.
Emphysema
Pneumothorax
Bronchitis
Pneumonia
Pleuritis
Asthma
Renal Dz.
Liver Dz.
Peripheral venous insufficiency
Aspiration of foreign body
Aspiration of gastric contents

