sample medical report of a patient with coronary disese

by Carley Baumbach 9 min read

Case Report: An elderly man with coronary artery disease and a …

12 hours ago  · A 72-year-old man with a history of hypertension, coronary artery disease, congestive heart failure, anxiety and a pacemaker presents to the emergency department for seven hours of non-radiating chest pain associated with dyspnea. He denies syncope, palpitations, fever, cough or other complaints. Exam: Vital signs are normal. Exam is normal. >> Go To The Portal


How do you explain CAD to a patient?

CAD happens when coronary arteries struggle to supply the heart with enough blood, oxygen and nutrients. Cholesterol deposits, or plaques, are almost always to blame. These buildups narrow your arteries, decreasing blood flow to your heart. This can cause chest pain, shortness of breath or even a heart attack.

How do you diagnose someone with CAD?

He or she may suggest one or more diagnostic tests as well, including:Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. ... Echocardiogram. ... Exercise stress test. ... Nuclear stress test. ... Cardiac catheterization and angiogram. ... Cardiac CT scan.

How do you write a complete cardiac diagnosis?

The four elements of a complete diagnosis are: Etiology, anatomy, physiology, and cardiac status and prognosis. In many cases, no additional data are needed and no additional data should be collected.

How do you monitor someone with coronary heart disease?

A number of different tests are used to diagnose heart-related problems, including:electrocardiogram (ECG)exercise stress tests.X-rays.echocardiogram.blood tests.coronary angiography.radionuclide tests.MRI scans.More items...

What are the 4 main coronary arteries?

The Coronary Arteries are the blood vessels that supply blood to your heart. They branch off of the aorta at its base. The right coronary artery, the left main coronary, the left anterior descending, and the left circumflex artery, are the four major coronary arteries.

Does ECG show coronary artery disease?

An ECG can show both stable CAD and acute coronary syndrome.

How do you write a medical history of a patient?

This article explains how.Step 1: Include the important details of your current problem. Timing - When did your problem start? ... Step 2: Share your past medical history. List all your past medical problems and surgeries. ... Step 3: Include your social history. ... Step 4: Write out your questions and expectations.

How do you write a present history of a patient?

It should include some or all of the following elements:Location: What is the location of the pain?Quality: Include a description of the quality of the symptom (i.e. sharp pain)Severity: Degree of pain for example can be described on a scale of 1 - 10.Duration: How long have you had the pain.More items...

How do you write a history taking a patient?

Procedure StepsIntroduce yourself, identify your patient and gain consent to speak with them. ... Step 02 - Presenting Complaint (PC) ... Step 03 - History of Presenting Complaint (HPC) ... Step 04 - Past Medical History (PMH) ... Step 05 - Drug History (DH) ... Step 06 - Family History (FH) ... Step 07 - Social History (SH)More items...

How do you describe an ECG?

An electrocardiogram (ECG or EKG) records the electrical signal from the heart to check for different heart conditions. Electrodes are placed on the chest to record the heart's electrical signals, which cause the heart to beat. The signals are shown as waves on an attached computer monitor or printer.

What are the early warning signs of heart disease?

SymptomsChest pain, chest tightness, chest pressure and chest discomfort (angina)Shortness of breath.Pain, numbness, weakness or coldness in your legs or arms if the blood vessels in those parts of your body are narrowed.Pain in the neck, jaw, throat, upper abdomen or back.

What is the difference between coronary heart disease and cardiovascular disease?

Cardiovascular disease is the term for all types of diseases that affect the heart or blood vessels, including coronary heart disease (clogged arteries), which can cause heart attacks, stroke, congenital heart defects and peripheral artery disease.