Cardiology

[remark]Cardiology Clinic Evaluation[/remark]

Patient Name: [text name="patient_name" default=""]

Visit Date: [date name="visit_date" default="MM/DD/YYYY"]

Chief Complaint: [radio name="chief_complaint" value="Chest pain|Palpitations|Shortness of breath|Fatigue|Edema|Dizziness|Other"]

History of Present Illness: 
Patient presents with chief complaint of [chief_complaint]. [textarea name="history_of_present_illness" default=""]

Past Medical History: 
Patient has a history of [past_medical_history]. [radio name="past_medical_history" value="Hypertension|Diabetes|Hyperlipidemia|Coronary artery disease|Congestive heart failure|Atrial fibrillation|Other"]
[textarea name="other_past_medical_history" default=""]

Medications: 
Patient is currently taking the following medications:
- [ ] Aspirin ___ mg daily
- [ ] Lisinopril ___ mg daily
- [ ] Metoprolol ___ mg twice daily
- [ ] Simvastatin ___ mg daily
[textarea name="medications" default=""]

Allergies: 
Patient has allergies to [allergies]. [checkbox name="allergies" value="Penicillin|Sulfa drugs|Aspirin|Other"]
[textarea name="other_allergies" default=""]

Family History: 
Family history includes [family_history]. [checkbox name="family_history" value="Coronary artery disease|Hypertension|Diabetes|Congenital heart disease|Other"]
[textarea name="other_family_history" default=""]

Social History: 
Patient's social history includes [social_history]. [checkbox name="social_history" value="Smoking|Alcohol use|Illicit drug use|Physical inactivity|Other"]
[textarea name="other_social_history" default=""]

Review of Systems: 
Patient reports experiencing [review_of_systems]. [checkbox name="review_of_systems" value="Chest pain|Palpitations|Shortness of breath|Edema|Cough|Wheezing|Dyspnea on exertion|Abdominal pain|Nausea|Vomiting|Headache|Dizziness|Syncope|Other"]
[textarea name="other_review_of_systems" default=""]

Physical Examination: 
Physical examination reveals [physical_exam]. [checkbox name="physical_exam" value="Well-appearing|Alert and oriented|No acute distress|Regular rhythm|No murmurs|Normal S1 and S2|Clear breath sounds|No wheezing|No crackles|Soft abdomen|Non-tender|No organomegaly|Cranial nerves intact|Normal gait|No edema|Normal pulses|Other"]
[textarea name="other_physical_exam" default=""]

Electrocardiogram (ECG) Findings: 
The ECG shows [ecg_findings]. [textarea name="ecg_findings" default=""]

Diagnostic Tests and Results: 
Other diagnostic test results:
- [ ] Test 1: [Result]
- [ ] Test 2: [Result]
- [ ] Test 3: [Result]
[textarea name="diagnostic_tests_results" default=""]

Assessment and Plan: 
- Working Diagnosis: [working_diagnosis]
- Differential Diagnosis: [differential_diagnosis]
- Plan:
  - Medications: [ ] Continue current medications [ ] Adjust current medications [ ] Prescribe new medications [ ] Other
  - Medication Changes: [Specify medication changes if chosen 'Other' above.]
  - Lifestyle Recommendations: [ ] Dietary modifications [ ] Exercise program [ ] Smoking cessation [ ] Other
  - Other Lifestyle Recommendations: [Specify other lifestyle recommendations if chosen 'Other' above.]
  - Follow-up: [ ] Follow up in 2 weeks [ ] Follow up in 4 weeks [ ] Follow up in 8 weeks [ ] Other
  - Follow-up Instructions: [Specify follow-up instructions if chosen 'Other' above.]
  - Referrals: [ ] Cardiac specialist [ ] Cardiac rehabilitation [ ] Nutritionist [ ] Other
  - Referral Details: [Specify referral details if chosen 'Other' above.]
  - Patient Education: [Education provided to the patient regarding their condition and management.]
[textarea name="assessment_and_plan" default=""]

Treatment Regimen:
- [ ] Aspirin 325 mg daily
- [ ] Lisinopril 10 mg daily
- [ ] Metoprolol 25 mg twice daily
- [ ] Simvastatin 20 mg daily
[textarea name="other_treatment_regimen" default=""]

Additional Notes:
[textarea name="additional_notes" default=""]

[comment memo="This template is intended for use by cardiology residents during patient evaluations in the cardiology clinic."]

[mark memo="memo" name="cardiology_resident_template"]