Critical Care History and Physical Examination

Chief complaint: Reason for admission to the ICU.

History of present illness: This section should included pertinent chronological events leading up to the hospitalization. It should include events during hospitalization and eventual admission to the ICU. Prior cardiac history: Angina (stable, unstable, changes in frequency), exacerbating factors (exertional, rest angina). History of myocardial infarction, heart failure, coronary artery bypass graft surgery, angioplasty. Previous exercise treadmill testing, ECHO, ejection fraction. Request old ECG, ECHO, impedance cardiography, stress test results, and angiographic studies. Chest pain characteristics:

A. Pain: Quality of pain, pressure, squeezing, tightness

B. Onset of pain: Exertional, awakening from sleep, relationship to activities of daily living (ADLs), such as eating, walking, bathing, and grooming.

C. Severity and quality: Pressure, tightness, sharp, pleuritic

D. Radiation: Arm, jaw, shoulder

E. Associated symptoms: Diaphoresis, dyspnea, back pain, GI symptoms.

F. Duration: Minutes, hours, days.

G. Relieving factors: Nitroclycerine, rest.

Cardiac risk factors: Age, male, diabetes, hypercholesteremia, low HDL, hypertension, smoking, previous coronary artery disease, family history of arteriosclerosis (eg, myocardial infarction in males less than 50 years old, stroke).

Congestive heart failure symptoms: Orthopnea (number of pillows), paroxysmal nocturnal dyspnea, dyspnea on exertional, edema. Peripheral vascular disease symptoms: Claudication, transient ischemic attack, cerebral vascular accident. COPD exacerbation symptoms: Shortness of breath, fever, chills, wheezing, sputum production, hemoptysis (quantify), corticosteroid use, previous intubation.

Past medical history: Peptic ulcer disease, renal disease, diabetes, COPD.

Functional status prior to hospitalization. Medications: Dose and frequency. Use of nitroglycerine, beta-agonist, steroids. Allergies: Penicillin, contrast dye, aspirin; describe the specific reaction (eg, anaphylaxis, wheezing, rash, hypotension). Social history: Tobacco use, alcohol consumption, intravenous drug use. Review of systems: Review symptoms related to each organ system.

Your Heart and Nutrition

Your Heart and Nutrition

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