急診模板: CV

• Chest pain, ACS

Chest pressure/ tightness/ pain, radiated to back/ jaw/ neck/ left arm/ right arm for____, since____

Sudden/ Gradual onset, excertional induced, dull pain/ tearing sensation /sharp pain/ stinging pain/ pleuritic pain/ burning sensation

Duration:

Aggravated by lying down/ sitting up/ walking/ exercising/ climbing stairs

Relieved by taking NTG/ taking medicine/ lying down/ sitting up/ resting

Nausea (-), vomiting (-), diaphoresis (-), exertional dyspnea (-), orthopnea (-)

Cough (-), sputum (-), color (-), rhinorrhea (-), sore throat (-)

Abdominal pain (-), constipation (-)

Dysuria(-), frequency (-), urgency (-)

Recent trauma (-), Surgery history (-)

Recent forceful vomiting after drinking alcohol (-), dysphagia (-)

CV risk factor:

-DM (-), HTN (-), Dyslipidemia (-), Obesity (-), Smoking (-), Physical inactivity (-),

-Age (-), Sex (-), FHx(-)

• Hypertension

BP, when, resistant to medication

Headache (), seizure (), stroke (), blurred vision ()

Chest pain ()/ radiation to back (), chest tightness (), dyspnea (), orthopnea (), bil leg swelling ()

Urine output (), hematuria (), dizziness (), palpitation ()

Current medication: titration (), changing ()

Change in diet ()

Use of steroids ()

Pheochromocytoma 5P:

-Pressure: hypertensive ()

-Pain: headache (), chest pain ()    

-Palpitations: tachycardia (), tremor (), weight loss (), fever ()

-Perspiration () 大量流汗

-Pallor ()

PHx:

HTN (), Aortic dissection (), ischemic stroke ()  

• Syncope

Micturition, cough, defecation, standing for too long, 打針

Turning head, shaving

Orthostatic hypotension, postural change

Seizure-like movement

Current medication:

PE:

Heart: regular/ irregular heartbeats, murmur (-),

Mx

EKG, CBC, BCS

OPD, Holter, Adm EPS