308 lines
6.3 KiB
Plaintext
308 lines
6.3 KiB
Plaintext
English French Notes Complete/Exclude
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TOTAL VPBS,
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% OF BTS
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TOTAL ECTOPICS,
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AVE/HOUR
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MAX/HOUR
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BLOCKED APCS
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BEATS IN RUNS
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RUNS SV-T
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BEATS IN LONGEST RUN
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BEATS FASTEST RUN AT
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BTS FASTEST RUN AT
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PERFORMED BY:
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DATE PERFORMED:
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APPROVED BY:
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DATE APPROVED:
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DATE OF ORIGINAL CONSULT:
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INDICATION(S) FOR PERFORMANCE:
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PERIPHERAL BLOOD SMEAR:
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NO. CELLS COUNTED:
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NEUTROPHILS:
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ORTHOCHROMATIC NORMOBLASTS:
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BANDS:
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POLYCHROMATIC NORMOBLASTS:
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METAMYELOCYTES:
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BASOPHILIC NORMOBLASTS:
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MYELOCYTES:
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PRONORMOBLASTS:
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PROMYLOCYTES:
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LYMPHOBLASTS:
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MYELOBLASTS:
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PLASMA CELLS:
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EOSINOPHILS:
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MONOCYTES:
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BASOPHILS:
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HISTIOCYTES:
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LYMPHOCYTES:
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CELLULARITY:
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BLOOD PRESSURE:
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VENT RATE:
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PR INTERVAL:
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INSTRUMENT DX:
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CONFIRMATION STATUS:
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COMPARISON:
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INTERPRETED BY:
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Ward/Clinic:
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Bronchoscopist:
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Fellow:
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2nd Fellow:
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SERIAL NUMBER:
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ATTENDING PHYSICIAN:
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FELLOW-1st:
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FELLOW-2nd:
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THRESHOLD (VOLTS):
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RESISTANCE (OHMS):
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P WAVE AMPLITUDE (mV):
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PSA USED:
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LEAD EXPLANT REASON:
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PACING INDICATION:
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RISK FACTORS:
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PSC STATUS:
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SUDDENESS:
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COMMENTS AND RECOMMENDATIONS:
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INTERPRETED BY:
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REVIEWED BY:
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HOSPITAL WHERE IMPLANTED:
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FIRST SCHEDULED FOLLOW-UP:
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NON-MAG RATE
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MAGNET RATE
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NON-MAG PULSE WIDTH
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MAGNET PULSE WIDTH
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OTHER INDICATOR
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NUMBER OF PULSE GENERATORS:
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LAST PREVIOUS IMPLANT:
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INCIPIENT MALFUNCTION:
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PACING FAILURE:
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GENERATOR EXPLANT DATE:
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REASON FOR CHANGE:
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SUDDENESS:
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CALLER:
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BASIC RHYTHM:
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PERCENT OF PACED BEATS:
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PULSE INTERVAL (mSec)
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RATE (BPM)
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PULSE WIDTH (mSec)
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MEASURED LEAD AMPLITUDE (mV)
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RATIO (T/L)
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THRESHOLD WIDTH
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THRESHOLD AMPLITUDE
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RATE UPPER LIMIT:
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HYSTERESIS:
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PULSE WIDTH (ATRIAL mSec):
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PULSE WIDTH (VENT. mSec):
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SENSITIVITY (ATRIAL mV):
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SENSITIVITY (VENT. mV):
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REFRACTORY PERIOD (ATRIAL):
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REFRACTORY PERIOD (VENT.):
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BATTERY VOLTAGE:
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BATTERY RESISTANCE:
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REASON FOR REPROGRAMMING:
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R WAVE AMPLITUDE (mV):
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PACING INDICATION:
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ICD9 CODE
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BACK GROUND INFORMATION
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Home phone:
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Work phone:
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Maritus status:
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Employment status:
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Occupation:
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DEATH - ADMIN.
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Lost or death status:
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Death date:
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Disease activity:
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Autopsy available:
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Cause of Death:
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Chart type:
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Observer:
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DEC number:
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Visit number:
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Rheumatic:
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Measurements:
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SYMMETRICAL ARTHRITIS:
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GRIP STRENGTH-LEFT:
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SUB-CUTANEOUS NODULES:
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GRIP STRENGTH-RIGHT:
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SYNOVIAL (BAKER'S) CYST:
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SCHOBER TEST (10 cm BASE):
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TOPHI:
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CHEST EXPANSION:
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TENOSYNOVITIS(TENDON RUBS):
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OCCIPUT-WALL:
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TEMPORAL ARTERY TENDERNESS:
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FINGER-TO-PALM CREASE-LEFT:
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COSTOCHONDRITIS:
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FINGER-TO-PALM CREASE-RIGHT:
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INTERINCISOR DISTANCE:
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Miscellaneous:
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SCHIRMER TEST:
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FUNCTIONAL CLASS (ACR):
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DISEASE SEVERITY-PAT. ESTIMATE:
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DISEASE SEVERITY-PHY. ESTIMATE:
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Joint Examination:
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Left
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Right
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FINGERS-DIP
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MCPS:
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1st CARPOMETACARPAL:
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WRIST:
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ELBOW:
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SHOULDER:
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TMJ:
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COSTOCHONDRAL:
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SACROILIAC:
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HIP:
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KNEE:
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ANKLE:
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MTP:
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TOES-PIP:
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CERVICAL SPINE:
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THORACIC SPINE:
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LUMBAR SPINE:
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PATIENT PHYSICAL EXAMINATION
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Systolic pressure
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Diastolic pressure
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Uveitis
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Lymph Node Enlargement
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Cataract
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Muscle Tenderness
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Iritis
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Muscle Weakness - Dital
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Oral Ulcers
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Hepatomegaly
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Rales
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Splenomegoly
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Pleural Rub
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Muscle Weakness - Proximal
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Pleural Effusion
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Muscle Atrophy
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Pericardial Rub
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Psychosis
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Systolic Murmur
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Organic Brain Syndrome
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Diastolic Murmur
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Motor Neurophathy
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Sensory Neurophathy
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Heliotrope Eyelids
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Telangiectasis
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Rash - Malar
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Cutaneous Vasculitis
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Psoriasis
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Periungal Erythema
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Rash - Discoid
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Keratodermia Blennorrhagica
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Rash - JRA
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Knuckle Erythema
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Palpable Purpura
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Digital Ulcers
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Sclerodactyly
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Nail Pitting
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Scleroderma - Extremity
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Skin Ulcers
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Scleroderma - Generalized
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Erythema Nodosum
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Morphea
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Sysmmetrical Arthritis
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Dactylitis
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Tophi
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Sub-Cutaneous Nodules
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Synovial (Baker's) Cyst
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Heel Pain
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Tenosynovitis (Tendon Rubs)
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Temporal Artery Tenderness
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Costochondritis
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Grip Strength - left
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Grip Strength - Right
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Schober Test (10 cm Base)
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Chest Expansion
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Occiput - Wall
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Finger-to-Palm Crease - left
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Finger-to-Palm Crease - Right
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Interincisor Distance
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Schirmer Test
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Walk Time (50 feet)
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Functional Class (ARA)
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Disease Severity - Patient Estimate
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Disease Severity - Physician Estimate
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Fingers - DIPs
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Fingers - PIPs
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MCPs
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First Carpomentacarpal
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Wrist
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Elbow
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Shoulder
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Sternoclavicular
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Knee
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Ankle
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Toes - PIP
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Cervical Spine
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Lumber Spine
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Patient History
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Head,Eyes,Ears,Nose,Mouth:
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BLURRED VISION:
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DRY EYES:
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Musculosketal:
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RINGING IN EARS:
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STIFF IN THE MORNING HOW LONG:
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HEARING DIFFICULTIES:
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JOINT PAIN:
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MOUTH SORES:
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JOINT SWELLING:
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DRY MOUTH:
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LOW BACK PAIN:
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LOSS,CHANGE IN TASTE:
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MUSCLE PAIN:
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HEADACHE:
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NECK PAIN:
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DIZZINESS:
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NUMBNESS OR TINGLING:
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FEVER:
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SWELLING OF LEGS:
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NIGHT SWEATS:
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WEAKNESS OF MUSCLES:
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Chest, Lung, and Heart:
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Neurologic and Psychologic:
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CHEST PAIN/TAKING DEEP BREATH:
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DEPRESSION:
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SHORTNESS OF BREATH:
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INSOMNIA:
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WHEEZING(ASTHMA):
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NERVOUSNESS:
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SEIZURES OR CONVULSION:
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TIREDNESS:
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TROUBLE REMEMBERING/THINKING:
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Gastrointestinal Tract:
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Skin:
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LOSS OF APPETITE:
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EASY BRUISING:
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DIFFICULTY SWALLOWING:
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FACIAL SKIN TIGHTENING:
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NAUSEA:
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HIVES OR WELTS:
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HEARTBURN,INDIGESTION,BELCHING:
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LOSS OF HAIR:
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VOMITING:
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ITCHING:
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PAIN/DISCOMFORT UPPER ABDOMEN:
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RASH:
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JAUNDICE:
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RASH OVER CHEEKS:
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LIVER:
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SKIN COLOR CHANGE IN FINGERS:
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PAIN/CRAMPS LOWER ABDOMEN:
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SUN SENSITIVITY:
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DIARRHEA(FREQUENT,WATERY):
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CONSTIPATION:
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BLK/TARRY STOOL(NOT FROM IRON:
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Genitourinary:
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Blood:
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URINE PROTEIN:
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LOW WHITE BLOOD COUNT:
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BLOOD IN URINE:
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LOW PLATELETS:
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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