Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Chest pain (angina pectoris): describe characteristics (location, duration, frequency, aggravating/relieving factors)
Shortness of breath (dyspnea) – may occur with exertion or at rest
Fatigue
Other symptoms suggestive of ischemia (e.g., sweating, nausea)
II. History of Present Illness:
Onset and duration of symptoms
Risk factors for CAD (hypertension, hyperlipidemia, diabetes, smoking history, family history)
Previous episodes of chest pain or angina
Stress testing results (if available)
Hospitalizations for cardiac events (e.g., myocardial infarction)
III. Past Medical History:
Comorbid conditions affecting cardiovascular health (diabetes, hypertension, peripheral artery disease)
Previous surgeries (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI))
IV. Medications:
Current medications for CAD (antiplatelet agents, statins, beta-blockers, ACE inhibitors/ARBs, nitrates)
Medications for other medical conditions
V. Social History:
Smoking history (current or past smoker, quit date)
Diet and exercise habits
Occupational stress
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
General appearance (signs of distress)
Cardiovascular exam:
Blood pressure (elevated in some cases)
Heart sounds (presence of murmurs)
Peripheral pulses (weak or absent pulses in extremities may suggest peripheral artery disease)
VII. Diagnostic Studies (consider as appropriate):
Electrocardiogram (ECG) – may show signs of ischemia or previous myocardial infarction
Chest X-ray – may show signs of heart enlargement or pulmonary edema
Echocardiogram – assesses heart function, wall motion abnormalities
Stress testing (exercise treadmill test or myocardial perfusion imaging) – evaluates for ischemia with exertion
Coronary angiography (gold standard for diagnosis) – visualizes coronary arteries and blockages
VIII. Assessment:
Confirmation of CAD diagnosis based on clinical presentation, risk factors, and imaging studies
Severity of CAD (extent of coronary artery blockage)
Functional status (angina classification – Canadian Cardiovascular Society (CCS) angina class)
Risk stratification for future cardiac events
IX. Plan:
Treatment plan focuses on lifestyle modifications and risk factor management:
Smoking cessation (if applicable)
Dietary modifications (lipid-lowering diet)
Weight management (if overweight or obese)
Regular exercise program
Medications:
Antiplatelet therapy (aspirin, clopidogrel) to prevent blood clots
Statins to lower LDL cholesterol
Beta-blockers to reduce heart rate and blood pressure
ACE inhibitors or ARBs for blood pressure control and potential cardioprotective effects
Nitrates for angina relief (short-acting or long-acting)
Revascularization procedures (PCI or CABG) – may be considered for severe CAD or inadequate symptom control with medications.
Cardiac rehabilitation program to improve exercise capacity and quality of life.
X. Prognosis:
Discuss the importance of lifestyle modifications and medication adherence to manage CAD and prevent complications (heart attack, stroke, heart failure).
Address the patient’s anxieties and concerns related to the diagnosis.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, adherence to recommendations, and need for emotional support.
XII. Resources:
Consider providing patient education materials on coronary artery disease from reputable sources (e.g., American Heart Association, American College of Cardiology).