308 lines
7.2 KiB
Plaintext
308 lines
7.2 KiB
Plaintext
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English French Notes Complete/Exclude
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BURNING ON URINATION:
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LOW RED BLOOD COUNT:
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KIDNEY PROBLEMS:
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Females Only:
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PREGNANT:
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Males Only:
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DISCHARGE FROM PENIS:
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IMPOTENCE:
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OTHER:
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RASH/ULCERS ON PENIS:
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PATIENT LABORATORY INFORMATION
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Aldolase
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Anti-DNA Antibody
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Anti-skeletal muscle
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Alkaline phosphatase
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Anti-RNP
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Urea nitrogen
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Hepatitis B Antibody
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Hepatitis B Antigen
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Cholesterol
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Complement CH50
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Cryoglobulins
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Creatinine
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Complement
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Glucose
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Complement C4
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HLA B27
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Bilirubin, total
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Latex fixation
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Protein, total
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Uric acid
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Salicylate
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UR Glucose
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UR Protein
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RBC/HPF
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WBC/HPF
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Granular/cast/lpf
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Choloride
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WBC/CASTS/LPF
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Bicarbonate
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Creatinine Clearance
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Neutrophil
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Bands
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Lymphs
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Monocytes
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Eosino
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Baso
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Platelet
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Reticulocytes
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Westergren ESR
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Protrhombin time
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Partial thromboplastin
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NARRATIVE HISTORY
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Physical Examination
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General:
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LYMPH NODE ENLARGEMENT:
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UVEITIS/IRITIS:
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MUSCLE TENDERNESS:
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CONJUNCTIVITIS/EPISCLERITIS:
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MUSCLE WEAKNESS-DISTAL:
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CATARACT:
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MUSCLE WEAKNESS-PROXIMAL:
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ORAL ULCERS:
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MUSCLE ATROPHY
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RALES:
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PSYCHOSIS:
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PLEURAL RUB/
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CLINICAL PLEURISY:
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ORGANIC BRAIN SYNDROME:
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PLEURAL EFFUSION:
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MOTOR NEUROPATHY:
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PERICARDIAL RUB/PERICARDITIS:
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SENSORY NEUROPATHY:
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CUTANEOUS VASCULTITIS:
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RASH-MALAR:
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PALPABLE PUPURA:
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RASH-DISCOID:
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SKIN ULCERS:
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RASH-JRA:
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ERYTHEMA NODOSUM:
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RASH-SLE,NON-MALAR:
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PERIUNGAL ERYTHEMA:
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RASH-OTHER:
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HELIOTROPE EYELIDS:
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KNUCKLE ERYTHEMA:
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TELANGIECTASIS:
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SUBCUTANEOUS CALCIFICATIONS:
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SCLERODACTYLY:
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KERATODERMIA BLENNORRHAGICA:
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SCLERODERMA-EXTREMITY:
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DACTYLITIS:
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SCLERODERMA-GENERALIZED:
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NAIL PITTING:
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MORPHEA:
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PSORIASIS:
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DIGITAL ULCERS:
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HEEL PAIN:
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HEALTH ASSESSMENT
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Questionnaire date:
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Study status:
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Drug Study:
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Dressing and Grooming:
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Arising:
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Eating:
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Walking:
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Hygiene:
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Reach:
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Activities:
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Pain Scale:
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II. CLINICAL DATA
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Sex
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Age
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NYHA functional class
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Creatinine
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III. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA
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LVEDP
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Lv Contraction Score (from contrast or
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Aortic systolic pressure
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radionuclide angiogram or 2D echo)
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*PA systolic pressure
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*PAW mean pressure
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Grade Ejection Fraction Definition
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*patients having right heart cath.
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Range
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Percent left main stenosis
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Number of other major coronary
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arteries (LAD,right with PDA,
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circumflex with marginals)
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with stenosis(es) => 50%
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IV. OPERATIVE RISK SUMMARY DATA
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Physician's preoperative
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estimate of operative
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V. OPERATIVE DATA
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CABG distal anastomoses:
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number with vein
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number with IMA
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Great vessel repair requiring
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Other(not checked above)
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Date of death
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Renal failure requiring
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Repeat cardiopulmonary
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Repeat Cardiopulmonary
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TIME TEST:
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AGE:
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WT LBS:
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REF PHYS:
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ETT PROTOCOL:
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HYPERVENTILATION:
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TARGET HR:
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RESTING EKG:
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ONSET CP
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PEAK EX
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SBP/DBP
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ST/SLP
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RPP/1000
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MIN:SEC
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PEAK MPH:
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% TARGET HR:
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TIME ST SEGMENT RETURN TO BASELINE:
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SIGNIFICANT ARRHYTHMIAS:
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BLOOD PRESSURE CHANGES:
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OTHER EKG CHANGES:
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COMPLICATIONS:
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EKG TECH:
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ATTN PHYS:
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-------------------------------VENTRICULAR STUDY----------------------------
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PREMEDICATION:
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RECORDING SITE SITE:
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VENTRICULAR THRESHOLD (mA):
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REPETITIVE RESPONSES
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VENT. EFF. REFR. PERIOD
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BURST PACING (# REP. RESPONSES):
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SHORTEST BURST CL:
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INITIATION SEQUENCE OF V-T:
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DURATION OF V-T/V-F:
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V-T CYCLE LENGTH:
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AXIS:
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TERMINATION OF VT:
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PACE OUT CYCLE LENGTH OF V-T:
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CARDIOVERSION (J):
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RHYTHM:
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MEDICATIONS ON DISCHARGE:
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CATHETERIZATION REPORT
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ECHO REPORT
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ECG REPORT
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EP REPORT
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HOLTER REPORT
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RHEUMATOLOGY REPORT
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ETT REPORT
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Enter patient name or the date & time:
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Pg.
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CONFIDENTIAL
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PROCEDURE DATE/TIME:
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Select Patient Name or Date of Procedure to Delete:
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ARE YOU SURE YOU WANT TO DELETE
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Procedure Deleted
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A-LEAD REPORT
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V-LEAD REPORT
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GENERATOR IMPLANT REPORT
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PACEMAKER SURVEILLANCE REPORT
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COMBINED IMPLANT/LEADS PROCEDURES
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Enter Patient name or Date of Generator Implant:
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Generator Information....
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Atrial Lead Data....
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Ventricular Lead Data...
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GENERATOR DATA...
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Ventricular
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Atrial
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Lead data entered for this patient
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Lead implanted on
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DEMOGRAPHIC INFORMATION
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ACTIVE PATIENT LIST
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This report has been set up to print with a line length of 132
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characters. Select a device that uses a 132 character line length.
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<RETURN> to continue
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PACEMAKER ACTIVE PATIENT LIST
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<RETURN> to Continue
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EAST PSC FOLLOW-UP
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REGISTRY ONLY
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WEST PSC FOLLOW-UP
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Pg.
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GENERATOR IMPLANT DATA
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V AND A LEAD IMPLANT DATA
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MFR MODEL
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SER. NO.
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Enter Patient Name, or Date and Time:
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SURVEILLANCE PROCEDURES
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*** SCREEN EDIT ***
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*** BRIEF EDIT ***
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MCAR(698
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TYPE OF LEAD NOT DEFINED FOR THIS PATIENT IN GENERATOR FILE
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PRESS RETURN TO CONTINUE:
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PACEMAKER SURVEILLANCE
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PATIENT HAS NO CURRENT GENERATOR IMPLANT LISTED IN GENERATOR FILE
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Entry Deleted
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FORM TRANSFER TO NATIONAL CENTER
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Select Reason for Transmission of this Report:
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Transfer Report to :
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WESTERN PACEMAKER CENTER
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EASTERN PACEMAKER CENTER
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Answer with 'E' for Eastern Center,'W' for Western Center, or 'B' for Both
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BOTH EASTERN AND WESTERN PACEMAKER CENTERS
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TRANSMIT REPORT
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MCR(
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PACEMAKER REPORT TRANSMISSION
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PACEMAKER CENTER REPORT
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REGISTRATION FORM DATA
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REASON(S) FOR REPORT:
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TELEPHONE FOLLOW-UP PROVIDED BY:
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EASTERN PACEMAKER SURVEILLANCE CENTER
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WESTERN PACEMAKER SURVEILLANCE CENTER
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LOCAL VAMC
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PULSE GENERATOR
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MFR:
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BEGINNING OF LIFE MAGNET RATE:
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END OF LIFE MAGNET RATE:
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TELEPHONES:
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IMPLANTING HOSPITAL:
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HOME:
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WORK:
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DATE OF INITIAL IMPLANT:
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RESPONSIBLE PHYSICIAN:
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MCPHYS(
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PULSE GENERATORS INCLUDING PRESENT:
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ATRIAL LEAD
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VENTRICULAR LEAD
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ATRIAL LEAD
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MODEL #:
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SERIAL #:
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DATE:
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PART 2
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ALTERNATE CONTACT
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ALTERNATE CONTACT ADDRESS
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TELEPHONE TRANSMITTER:
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MODEL #:
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IMPLANT PARAMETERS: ATRIAL LEAD
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THRESHOLD IN VOLTS
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THRESHOLD IN MAs
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AT .5 MS PW
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RESISTANCE AT 5 VOLTS
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R-WAVE OR P-WAVE
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PSA USED:
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SURVEILLANCE DATA
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PROGRAMMED SETTINGS
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PULSE WIDTH
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AMPLITUDE
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SENSITIVITY
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REFRACTORY PERIOD
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LOWER RATE LIMIT:
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UPPER RATE LIMIT:
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PACING MODE:
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CLINIC MEASUREMENTS
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PULSE WIDTH
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AMPLITUDE
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RATIO (T/L)
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THRESHOLD WIDTH
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THRESHOLD AMPLITUDE
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CAPTURE
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SENSE
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RATE NO MAGNET:
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RATE MAGNET:
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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