Congestive Heart Failure HISTORY_LIST ***** HISTORY OF PRESENT ILLNESS duration of dyspnea onset of dyspnea paroxysmal nocturnal dy spnea orthopnea edema pillows needed for sleeping doe exercise tolerance weight gain severity of dyspnea chest pain pleuritic pain cough fever chills sputum nausea vomiting diaphoresis palpitations nocturia fatigue syncope ***** HISTORY CHRONIC DISEASE SYSTEMIC DISORDERS past MI diabetes hypertension excessive salt intake coronary artery disease valvular disease arrhythmia Digoxin diuretics NSAIDS calcium channel blockers beta blockers PREVIOUS TESTS ECG Stress test Nuclear scan Echocardiogram SOCIAL HISTORY Smoking Cocaine use FAMILY HISTORY CAD heart failure hypercholesterolemia HTN MEDS_LAB_TESTS **** MEDS ***** LAB electrolytes BUN CBC CPK MB LDH ***** TESTS ECG CXR REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 VITALS BP Postural BP Pulse Temp Heart rate GENERAL Respiratory distress Anxiety NECK JVD at 45(,carotid pulse amplitude carotid pulse duration,carotid bruits REVIEW_OF_SYSTEMS_3 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge PHYSICAL_EVAL_1 CHEST breath sounds crackles wheezes rhonchi dullness to percussion unilateral hyperresonance HEART displaced PMI parasternal apical heave atrial fibrillation rubs decreased intensity of S1 paradoxical splitting of S2 presence of S3 gallop presence of S4 holosystolic apex murmur dyskinetic cardiac impulse enlarged apical impulse prolonged apical impulse displaced apical impulse Levine's sign (patient with clenched fist over sternum) ABDOMEN hepatojugular reflex ascites hepatomegaly liver tenderness abdominal distention EXTREMITIES pitting edema non-pitting edema extent of edema pulses cyanosis clubbing PHYSICAL_EVAL_2 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty: fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization for, psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia DIFF_DIAGNOSIS Heart failure MI PE Constrictive pericarditis Pleurisy Cardiomyopathy Valvular Dz. Emphysema Pneumothorax Bronchitis Pneumonia Pleuritis Asthma Renal Dz. Liver Dz. Peripheral venous insufficiency Aspiration of foreign body Aspiration of gastric contents