English French Notes Complete/Exclude BURNING ON URINATION: LOW RED BLOOD COUNT: KIDNEY PROBLEMS: Females Only: PREGNANT: Males Only: DISCHARGE FROM PENIS: IMPOTENCE: OTHER: RASH/ULCERS ON PENIS: PATIENT LABORATORY INFORMATION Aldolase Anti-DNA Antibody Anti-skeletal muscle Alkaline phosphatase Anti-RNP Urea nitrogen Hepatitis B Antibody Hepatitis B Antigen Cholesterol Complement CH50 Cryoglobulins Creatinine Complement Glucose Complement C4 HLA B27 Bilirubin, total Latex fixation Protein, total Uric acid Salicylate UR Glucose UR Protein RBC/HPF WBC/HPF Granular/cast/lpf Choloride WBC/CASTS/LPF Bicarbonate Creatinine Clearance Neutrophil Bands Lymphs Monocytes Eosino Baso Platelet Reticulocytes Westergren ESR Protrhombin time Partial thromboplastin NARRATIVE HISTORY Physical Examination General: LYMPH NODE ENLARGEMENT: UVEITIS/IRITIS: MUSCLE TENDERNESS: CONJUNCTIVITIS/EPISCLERITIS: MUSCLE WEAKNESS-DISTAL: CATARACT: MUSCLE WEAKNESS-PROXIMAL: ORAL ULCERS: MUSCLE ATROPHY RALES: PSYCHOSIS: PLEURAL RUB/ CLINICAL PLEURISY: ORGANIC BRAIN SYNDROME: PLEURAL EFFUSION: MOTOR NEUROPATHY: PERICARDIAL RUB/PERICARDITIS: SENSORY NEUROPATHY: CUTANEOUS VASCULTITIS: RASH-MALAR: PALPABLE PUPURA: RASH-DISCOID: SKIN ULCERS: RASH-JRA: ERYTHEMA NODOSUM: RASH-SLE,NON-MALAR: PERIUNGAL ERYTHEMA: RASH-OTHER: HELIOTROPE EYELIDS: KNUCKLE ERYTHEMA: TELANGIECTASIS: SUBCUTANEOUS CALCIFICATIONS: SCLERODACTYLY: KERATODERMIA BLENNORRHAGICA: SCLERODERMA-EXTREMITY: DACTYLITIS: SCLERODERMA-GENERALIZED: NAIL PITTING: MORPHEA: PSORIASIS: DIGITAL ULCERS: HEEL PAIN: HEALTH ASSESSMENT Questionnaire date: Study status: Drug Study: Dressing and Grooming: Arising: Eating: Walking: Hygiene: Reach: Activities: Pain Scale: II. CLINICAL DATA Sex Age NYHA functional class Creatinine III. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA LVEDP Lv Contraction Score (from contrast or Aortic systolic pressure radionuclide angiogram or 2D echo) *PA systolic pressure *PAW mean pressure Grade Ejection Fraction Definition *patients having right heart cath. Range Percent left main stenosis Number of other major coronary arteries (LAD,right with PDA, circumflex with marginals) with stenosis(es) => 50% IV. OPERATIVE RISK SUMMARY DATA Physician's preoperative estimate of operative V. OPERATIVE DATA CABG distal anastomoses: number with vein number with IMA Great vessel repair requiring Other(not checked above) Date of death Renal failure requiring Repeat cardiopulmonary Repeat Cardiopulmonary TIME TEST: AGE: WT LBS: REF PHYS: ETT PROTOCOL: HYPERVENTILATION: TARGET HR: RESTING EKG: ONSET CP PEAK EX SBP/DBP ST/SLP RPP/1000 MIN:SEC PEAK MPH: % TARGET HR: TIME ST SEGMENT RETURN TO BASELINE: SIGNIFICANT ARRHYTHMIAS: BLOOD PRESSURE CHANGES: OTHER EKG CHANGES: COMPLICATIONS: EKG TECH: ATTN PHYS: -------------------------------VENTRICULAR STUDY---------------------------- PREMEDICATION: RECORDING SITE SITE: VENTRICULAR THRESHOLD (mA): REPETITIVE RESPONSES VENT. EFF. REFR. PERIOD BURST PACING (# REP. RESPONSES): SHORTEST BURST CL: INITIATION SEQUENCE OF V-T: DURATION OF V-T/V-F: V-T CYCLE LENGTH: AXIS: TERMINATION OF VT: PACE OUT CYCLE LENGTH OF V-T: CARDIOVERSION (J): RHYTHM: MEDICATIONS ON DISCHARGE: CATHETERIZATION REPORT ECHO REPORT ECG REPORT EP REPORT HOLTER REPORT RHEUMATOLOGY REPORT ETT REPORT Enter patient name or the date & time: Pg. CONFIDENTIAL PROCEDURE DATE/TIME: Select Patient Name or Date of Procedure to Delete: ARE YOU SURE YOU WANT TO DELETE Procedure Deleted A-LEAD REPORT V-LEAD REPORT GENERATOR IMPLANT REPORT PACEMAKER SURVEILLANCE REPORT COMBINED IMPLANT/LEADS PROCEDURES Enter Patient name or Date of Generator Implant: Generator Information.... Atrial Lead Data.... Ventricular Lead Data... GENERATOR DATA... Ventricular Atrial Lead data entered for this patient Lead implanted on DEMOGRAPHIC INFORMATION ACTIVE PATIENT LIST This report has been set up to print with a line length of 132 characters. Select a device that uses a 132 character line length. to continue PACEMAKER ACTIVE PATIENT LIST to Continue EAST PSC FOLLOW-UP REGISTRY ONLY WEST PSC FOLLOW-UP Pg. GENERATOR IMPLANT DATA V AND A LEAD IMPLANT DATA MFR MODEL SER. NO. Enter Patient Name, or Date and Time: SURVEILLANCE PROCEDURES *** SCREEN EDIT *** *** BRIEF EDIT *** MCAR(698 TYPE OF LEAD NOT DEFINED FOR THIS PATIENT IN GENERATOR FILE PRESS RETURN TO CONTINUE: PACEMAKER SURVEILLANCE PATIENT HAS NO CURRENT GENERATOR IMPLANT LISTED IN GENERATOR FILE Entry Deleted FORM TRANSFER TO NATIONAL CENTER Select Reason for Transmission of this Report: Transfer Report to : WESTERN PACEMAKER CENTER EASTERN PACEMAKER CENTER Answer with 'E' for Eastern Center,'W' for Western Center, or 'B' for Both BOTH EASTERN AND WESTERN PACEMAKER CENTERS TRANSMIT REPORT MCR( PACEMAKER REPORT TRANSMISSION PACEMAKER CENTER REPORT REGISTRATION FORM DATA REASON(S) FOR REPORT: TELEPHONE FOLLOW-UP PROVIDED BY: EASTERN PACEMAKER SURVEILLANCE CENTER WESTERN PACEMAKER SURVEILLANCE CENTER LOCAL VAMC PULSE GENERATOR MFR: BEGINNING OF LIFE MAGNET RATE: END OF LIFE MAGNET RATE: TELEPHONES: IMPLANTING HOSPITAL: HOME: WORK: DATE OF INITIAL IMPLANT: RESPONSIBLE PHYSICIAN: MCPHYS( PULSE GENERATORS INCLUDING PRESENT: ATRIAL LEAD VENTRICULAR LEAD ATRIAL LEAD MODEL #: SERIAL #: DATE: PART 2 ALTERNATE CONTACT ALTERNATE CONTACT ADDRESS TELEPHONE TRANSMITTER: MODEL #: IMPLANT PARAMETERS: ATRIAL LEAD THRESHOLD IN VOLTS THRESHOLD IN MAs AT .5 MS PW RESISTANCE AT 5 VOLTS R-WAVE OR P-WAVE PSA USED: SURVEILLANCE DATA PROGRAMMED SETTINGS PULSE WIDTH AMPLITUDE SENSITIVITY REFRACTORY PERIOD LOWER RATE LIMIT: UPPER RATE LIMIT: PACING MODE: CLINIC MEASUREMENTS PULSE WIDTH AMPLITUDE RATIO (T/L) THRESHOLD WIDTH THRESHOLD AMPLITUDE CAPTURE SENSE RATE NO MAGNET: RATE MAGNET: #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################