Cardiology Admission History & Physical

Date/Time of Encounter: [Date and time of evaluation]

Location: [ED / telemetry / ICU / cath lab holding / step-down / floor]

Admitting Service/Attending: [Service and attending name]

Source of History: [patient / family / EMS / outside records]; [reliable / limited] (Note limitations such as altered mental status, sedation, or language barrier with interpreter used.)

Chief Complaint

[Patient-stated reason for seeking care in their own words] (If patient cannot provide, document reason and alternative source used.)

History of Present Illness

[One-sentence opener: age, sex, key cardiac history, and presenting syndrome]

[Narrative description of symptom onset, provocation/palliation, quality, radiation, severity, timing, associated symptoms, and progression] (Include pertinent negatives that narrow the differential. Summarize pre-hospital and ED course including treatments and response. Include key objective findings such as biomarker trend direction and ECG pattern without exhaustive data.)

(Embed baseline cardiology anchors in the narrative when simple; use labeled lines below if complex.)

Baseline functional status: [NYHA class / CCS angina class / functional description if class unknown; baseline O2 needs; dry weight if HF] (State unknown if unavailable.)

Known cardiac function: [Most recent EF with date, notable valvular disease and severity, pulmonary pressures if known] (State not available if unknown.)

Prior cardiac history: [Prior MI, PCI, CABG with approximate dates; prior cath findings; prior arrhythmias; prior HF admissions]

Cardiac devices: [Pacemaker / ICD / CRT / LVAD / prosthetic valves with indication and last interrogation] (State none or unknown if applicable.)

Risk context: [Coronary risk factors; stimulant or cocaine use; hypercoagulable risks; infectious risks] (Include only if relevant to presentation.)

Past Medical History

Cardiac History:

• [CAD: MI dates, PCI with vessel/stent, CABG with grafts]
• [Heart failure: phenotype, baseline EF, prior decompensations]
• [Arrhythmias: AF/flutter/VT, prior ablations or cardioversions]
• [Valvular disease: lesion, severity, prior interventions]
• [Structural or congenital heart disease]

Other Medical History: [CKD, diabetes, COPD, OSA, stroke/TIA, bleeding history, liver disease, malignancy with cardiotoxic therapies, other relevant conditions]

Surgical History: [Cardiac and non-cardiac procedures with dates]

Medications

• [Medication – dose, route, frequency]
• (Add additional medications as needed.)

Time-sensitive last doses: [Anticoagulants, antiplatelets, insulin, diuretics: last dose date/time] (State unknown if unavailable.)

Adherence: [Adherence status and barriers; recent changes or holds]

Sources: [patient / family / pharmacy / med list / outside records] (If incomplete, state reason and plan to reconcile.)

Allergies

• [Allergen – reaction type and severity]

Contrast reaction history: [none / prior reaction with type and management]

Heparin/HIT history: [none / prior HIT with details] (State unknown rather than NKDA if allergy history unavailable.)

Family History

[Premature CAD, sudden cardiac death, cardiomyopathy, channelopathies, aortopathy, familial hypercholesterolemia] (Omit section if noncontributory.)

Social History

• Tobacco: [current / former / never]; [pack-years]
• Alcohol: [Use pattern and quantity]
• Recreational drugs: [Type, specifically stimulants or cocaine if relevant]
• Living situation: [Residence, caregivers, support system, baseline independence]
• Diet/exercise/behaviors: [Sodium intake, exercise habits, CPAP use, weight management] (Include if relevant.)

(If unable to obtain, document reason.)

Review of Systems

• Cardiovascular: [chest pain or equivalents, dyspnea, orthopnea, PND, palpitations, syncope/presyncope, edema, weight changes]
• Vascular: [claudication]
• Neurologic: [focal deficits, confusion]
• Constitutional: [fever, infectious symptoms]

(Document pertinent positives and negatives relevant to the presenting syndrome.)

Physical Examination

Vital signs: [T, HR, BP, RR, SpO2 on room air / supplemental O2 delivery method]

• General: [Appearance and distress level]
• Neck: [JVP estimate in cm]; [carotid exam]
• Cardiovascular: [Rate, rhythm]; [murmurs with location/grade/radiation]; [gallops, rubs]; [peripheral perfusion]
• Lungs: [Work of breathing]; [breath sounds]; [crackles, wheezes]
• Abdomen: [Hepatomegaly, ascites] (Include if HF suspected.)
• Extremities: [Edema with grading]; [pulses]; [warmth, cyanosis]
• Neurologic: [Mental status]; [focal deficits] (Include if embolic concern.)

Volume status: [euvolemic / volume overloaded / volume depleted] (Support with JVP, edema grade, lung exam, weight change from baseline.)

Perfusion: [warm and well-perfused / cool with hypoperfusion] (Support with exam findings.)

Diagnostics

Labs: [Key admission values: cardiac biomarkers with trend, BNP/NT-proBNP, K, Mg, Cr, CBC, coagulation if anticoagulated, lactate if shock suspected, lipids/A1c if relevant] (Summarize with interpretation; avoid raw data dumps.)

ECG: [Date/time]; [rhythm]; [rate]; [ischemic or conduction changes]; [QTc]; [comparison to prior]

Imaging: [CXR interpretation]; [Echo if available: EF, wall motion, valves, RV function]; [Other relevant imaging]

Telemetry/Device: [Notable arrhythmias]; [pacing status]; [ICD therapies] (Include if applicable.)

Pending: [Key pending studies and what decisions they will inform]

Assessment and Plan

[1–3 sentence clinical summary: leading diagnosis or diagnostic framing, current stability, and key risks] (Use "concern for" or "consistent with" when diagnoses are uncertain.)

[Problem 1 – Primary presenting syndrome]

[Working diagnosis with key supporting data; differential if uncertainty is meaningful]

• Diagnostics: [Tests with rationale and how results will inform management]
• Therapeutics: [Medications with dose/route/frequency and rationale; procedures if planned]
• Monitoring: [Level of care, vitals frequency, telemetry, hemodynamic goals]
• Contingency: [Escalation plan if deterioration] (Include if applicable.)

[Problem 2]

(Repeat structure for additional active problems. Include only problems actively managed this admission.)

Coronary Disease Secondary Prevention

(Include if CAD or ACS.)

• [Antiplatelet plan]
• [Statin strategy and intensity]
• [Risk factor modification]

Heart Failure Optimization

(Include if HF.)

• GDMT: [Continue / hold / initiate with rationale]
• Diuresis: [Agent, dosing strategy, net fluid goal, weight target]

Anticoagulation

(Include if applicable.)

• [Indication, agent, dosing]
• [Bleeding considerations and monitoring]

Electrolytes

[Repletion targets and monitoring frequency] (Include if arrhythmia risk or active diuresis.)

VTE Prophylaxis

[Pharmacologic agent / mechanical / therapeutic anticoagulation in place]

Procedural Planning

(Include if procedure anticipated.)

• [Procedure, indication, timing]
• [NPO status, contrast precautions, access considerations]

Disposition and Orders

• Level of care: [ICU / step-down / telemetry / floor] with justification
• Activity: [bedrest / up with assistance / as tolerated]
• Diet: [cardiac diet / fluid restriction / sodium restriction / NPO]
• Monitoring: [Strict I&O; daily weights] (Include if volume concerns.)
• Follow-up items: [Obtain prior records, confirm baseline values, schedule device interrogation]

Code Status and Goals of Care

[Full code / DNR-DNI / other]; [Discussion held with patient/surrogate or plan to address]