Medical History Form. Part 1. Administrative Information

Transcription

1 Medical History Form ID NUMBER: FORM CODE: MHX VERSION:A 02/10/10 Contact Occasion 0 1 SEQ # Administrative Information 0a. Completion Date: / / 0b. Staff ID: Part 1 Instructions: Part 1 of this form is completed by participant-response. Affix the participant ID label above. 1. Prior Angina... No Yes Unknown [ Angina refers to evidence or knowledge of symptoms before this acute event described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia] Comment [KBR1]: Do we want to add Do you have a history of to the beginning of these first 7 questions? 1a. If YES, then choose one of the following: Existed > 2 weeks before admission Existed 2 weeks before admission 2. Previous Myocardial Infarction... No Yes Unknown [Diagnosed by physician and hospitalized for myocardial infarction] 3. Prior Percutaneous Coronary Intervention... No Yes Unknown 3a. If YES, most recent PCI date: / / 4. Prior Coronary Artery Bypass Surgery... No Yes Unknown 4a. If YES, most recent CABG date : / / 5. History of Stroke... No Yes Unknown 5a. If YES, then answer the following: Hemiplegia:... No Yes 6. History of TIA... No Yes Unknown [A focal neurological deficit (usually corresponding to the territory of a single vessel) that resolves spontaneously without evidence of residual symptoms at 24 hours] 7. History of peripheral arterial disease... No Yes Unknown [Peripheral arterial disease can include the following: (1) Claudication (pain in the muscles in the back of the legs), either with exertion or at rest (2) Amputation for arterial vascular insufficiency (3) Vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities (4) Documented aortic aneurysm (5) Positive noninvasive test (e.g., ankle brachial index less than 0.8). Medical History (MHX) Page 1 of 10

2 8. Do you have a history of congestive heart failure?... No Yes Unknown 8a. If YES, then classify heart failure: NYHA Class I No symptoms and no limitation in ordinary physical activity (e.g. shortness of breath when walking, climbing stairs etc). NYHA Class II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. NYHA Class III Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest. NYHA Class IV Severe limitations. Experiences symptoms at rest. Inability to carry out physical activity or symptoms at rest. 9. Do you currently smoke or have you smoked in the past?. No Yes If YES, answer the following: 9a. Current (within 1 month) Recent (stopped 1 month to 1 year prior) Former (stopped > 1 year prior) 9b. Years of smoking: 9c. Cigarettes smoked per day: cigarettes per day (1 = 1 or fewer per day) 10. Do you have a family history of coronary disease?... No Yes Unknown (As documented by direct blood relatives parents, siblings, children who have had any of the following before age 55: 1) angina, or 2) myocardial infarction, or 3) sudden cardiac death without obvious cause) In the three months prior to this visit today: 11. Were you exercising regularly?... No Yes Unknown 12. Were you following a low-cholesterol, low-fat diet?... No Yes Unknown 13. Were you participating in a cardiac rehabilitation program?... No Yes Unknown 14. Many people do not take their medications perfectly. In the three months before this hospitalization, did you ever miss taking your medications?... No Yes Unknown 15. Did any medical professional discuss with you the importance of taking your medications? Were you taking aspirin on a daily basis during the 7 days before you came to the hospital? Were you taking vitamins or supplements?... If yes, please list: Medical History (MHX) Page 2 of 10

3 Part 2 Instructions: Part 2 of this form is completed by chart abstraction. A. RISK FACTORS 18. Height:... inches 19. Weight:... lbs Note: For Questions 20 42, Unknown = No documentation of Positive or Negative History OR Unclear documentation. 20. Hypertension... No Yes Unknown (As documented by 1) diagnosis by a health care provider, or 2) SBP > 140 or DBP > 90 mmhg on at least 2 occasions, or 3) current use of antihypertensive medication) 21. Diabetes... No Yes Unknown (As documented by 1) diagnosis by a health care provider, or 2) current use of antidiabetic medication) 22. Dyslipidemia... No Yes Unknown (As documented by (1) diagnosis by a health care provider, or (2) current use of hypolipidemic medication) 23. History of cigarette smoking... No Yes Unknown If Yes, answer the following: a. Current (within 1 month) Recent (stopped 1 month to 1 year prior) Former (stopped > 1 year prior) b. Years of smoking: c. Cigarettes smoked per day: Cigarettes per day (1 = 1 or fewer per day) 24. Family history of coronary disease... No Yes Unknown (As documented by direct blood relatives parents, siblings, children who have had any of the following before age 55: 1) angina, or 2) myocardial infarction, or 3) sudden cardiac death without obvious cause) B. CARDIOVASCULAR DISEASE HISTORY 25. Angina... No Yes Unknown (As documented by evidence or knowledge of symptoms before the index ACS event described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia) Medical History (MHX) Page 3 of 10

4 26. Myocardial infarction... No Yes Unknown (As documented by 1) physician diagnosis, or 2) hospitalization for MI) 26a. If Yes, most recent date: / / 27. Percutaneous Coronary Intervention (PCI)... No Yes Unknown 27a. If Yes, most recent date: / / 28. Coronary Artery Bypass Surgery (CABG)... No Yes Unknown 28a. If Yes, most recent date: / / 29. Stroke... No Yes Unknown 29a. If Yes, most recent date: / / 30. TIA... No Yes Unknown (As documented by focal neurological deficit, usually corresponding to the territory of a single vessel, that resolves spontaneously without evidence of residual symptoms at 24 hour) 31. Peripheral Arterial Disease... No Yes Unknown (As documented by 1) claudication, either with exertion or at rest, 2) amputation for arterial vascular insufficiency, 3) vascular reconstruction, CABG, or PCI to the extremities, 4) aortic aneurysm, 5) positive noninvasive test (e.g., ankle brachial index < 0.8)) 32. Congestive heart failure... No Yes Unknown a. If Yes, NYHA class:.. I II III IV Medical History (MHX) Page 4 of 10

5 C. OTHER COMORBID ILLNESS HISTORY 33. Chronic lung disease... No Yes Unknown (As documented by 1) asthma, 2) chronic obstructive pulmonary disease, 3) chronic bronchitis, or 4) emphysema) 34. Kidney disease... No Yes Unknown 35. Liver disease... No Yes Unknown 35a. If Yes, severity: Mild (e.g. chronic hepatitis, or cirrhosis without complications such as varices, portal hypertension, encephalopathy, GI bleeding) Moderate/Severe (e.g. cirrhosis with complications such as varices, portal hypertension, encephalopathy, GI bleeding) 36. Rheumatologic disease... No Yes Unknown (As documented by lupus (SLE), polymyagia rheumatica (PMR), polymyositis, mixed connective tissue disease, polymyalgia rheumatica, or rheumatoid arthritis (RA)) 37. Peptic ulcer disease... No Yes Unknown (As documented by treatment for ulcer or history of GI bleed due to ulcer) Note: gastritis without ulcer does not count as peptic ulcer disease 38. AIDS... No Yes Unknown Note: not including those with asymptomatic HIV+ 39. Any cancer treated in the past 5 years. No Yes Unknown (e.g., breast, lung, colon, prostate, brain, etc.) 40. Leukemia (blood cancer)... No Yes Unknown (e.g., AML, CML, ALL, CLL, polycythemia vera) 41. Lymphoma (lymph node cancer)... No Yes Unknown (e.g., Hodgkins, lymphosarcoma, Waldenstrom s macroglobulinemia, myeloma, and other lymphomas) 42. Thyroid disease... No Yes Unknown a. If Yes, type:... Hyperthyroidism Hypothyroidism 43. Other co-morbid illness... No Yes a. b. c. Medical History (MHX) Page 5 of 10

6 D. INDEX ACUTE CORONARY SYNDROME (ACS) EVENT Comment [KBR2]: Need to renumber the rest of this section 27. Hospital Name: 28. Hospital admission date: / / 29. Transferred from another hospital?... No Yes If Yes: a. Hospital Name: b. If Yes, transfer date: / / 30. Date of ACS diagnosis: / / 31. Hospital discharge date: / / 32. Heart rate at initial hospital presentation:... bpm 33. SBP/DBP at initial presentation:... / mmhg 34. Killip class at initial presentation:... I II III IV 35. Cardiac arrest at initial presentation? No Yes 36. Heart rate at discharge:... bpm 37. SBP/DBP at discharge:... / mmhg E. ECG FINDINGS FOR INDEX ACS EVENT 38a. Admitting ECG available? No Yes a. Date of ECG: / / b. Time of ECG: : AM / PM Hour Minute (circle one) 38b. Pre-discharge ECG available? No Yes a. Date of ECG: / / b. Time of ECG: : AM / PM Hour Minute (circle one) Medical History (MHX) Page 6 of 10

7 39. ECG changes?... No Yes (If Yes, retain copy of ECG on which diagnosis is made, and a subsequent ECG after evolution of the changes) a. For the diagnostic ECG, indicate type(s) of ECG changes (check all that apply): ST-segment elevation 0.1 mv elevation in 2 or more contiguous leads Q waves greater 0.04 seconds in width and 0.1 mv in depth in at least 2 contiguous leads ST-segment depression > 0.05 mv in 2 more contiguous leads (includes reciprocal changes) T-wave inversion of at least 0.1 mv b. For the ECG after evolution of the changes, indicate the pattern:... Q wave non-q wave 40. Paced rhythm?... No Yes 41. Atrial fibrillation or flutter?... No Yes 42. Bundle branch block?... No Yes a. Type... RBBB LBBB b. Timing... New Old Unknown F. LABORATORY TESTS DURING HOSPITALIZATION FOR INDEX ACS EVENT 43. Troponin I or T performed?... No Yes a. Instrument:... ctni (cardiac troponin I) ctnt (cardiac troponin T) Other, specify: b. Assay:... Abbott AxSYM ADV Radiometer AQT90 Abbott Architect Response RAMP Abbott i-stat Roche E170 Beckman Access Accu Roche Elecsys 2010 Beckman Access hs-ctni Siemens Centaur Ultra biomerieux Vidas Ultra Siemens Dimension RxL Innotrac Aio! Siemens Immulite 2500 Inverness Biosite Triage Siemens Stratus CS Mitsubishi PATHFAST Siemens VISTA Nanosphere hs-ctni Singulex hs-ctni Ortho Vitros ECi ES Tosoh AIA II Other, specify: Medical History (MHX) Page 7 of 10

8 c. Troponin at initial hospital presentation:... ng/ml d. Troponin during hospitalization:... ng/ml (peak - prior to PCI or CABG if done) INITIAL IS DEFINED AS THE FIRST VALUE RECORDED DURING THE INDEX ACS HOSPITALIZATION 44. Initial creatinine... mg/dl 45. Initial total cholesterol:... mg/dl 46. Initial triglycerides:... mg/dl 47. Initial LDL:... mg/dl 48. Initial HDL:... mg/dl 49. Initial hemoglobin A1c:... % G. PROCEDURES DURING HOSPITALIZATION FOR INDEX ACS EVENT 50. Stress test?... No Yes If Yes, then answer the following: a. Date of test: / / b. Stress test type... Exercise Pharmacological If Exercise, to target heart rate?... No Yes c. Imaging type:... EKG only Nuclear PET Echocardiogram d. Ischemia Result... Positive Negative Equivocal e. Fixed defect indicating an old MI... Present Absent f. Other findings (e.g, hypotension, delayed hysteresis): Medical History (MHX) Page 8 of 10

9 51. LV function assessed during hospitalization? No Yes If Yes, then answer the following: a. Initial LVEF: % or check one Normal/Low normal Mildly reduced Mild-moderately reduced Moderately reduced Moderate-severely reduced Severely Reduced b. Mitral regurgitation noted?... No Yes c. EF method: (check one) Echocardiography (by ultrasound) Contract ventriculography (by cath/angiogram) Radionuclide ventriculography or SPECT on stress testing (nuclear) 52. Diagnostic cardiac catheterization? No Yes If Yes, then answer the following: a. Date: / / b. Maximum stenosis (%): LAD LCx RCx LM 53. PCI performed?... No Yes If Yes, then answer the following: a. Date: / / b. Stents placed: c. Stent type:... Bare metal Drug-eluting d. Complications of PCI?... No Yes If Yes, type (check all that apply): Bleeding Vascular complication Cardiac tamponade Arrhythmia Stroke Contrast reaction Acute renal failure Medical History (MHX) Page 9 of 10

10 54. Coronary Artery Bypass Surgery performed? No Yes a. Date: / / H. CURRENT MEDICATIONS No Yes Unknown Name Daily Dose Units 55. ACE inhibitors Angiotensin II receptor blockers. 57. Aspirin Clopidogrel Other antiplatelet agents Anticoagulants (e.g., Warfarin) Beta-blockers Calcium channel blockers Digitalis/Digoxin Other inotropic agent (not digitalis) 65. Diuretics Statin lipid-lowering agents Non-statin lipid-lowering agents. 68. Nitrates Vasodilators (not ACE inhibitors) PO hypoglycemic antidiabetic Insulin Antiarrhythmics Female hormone replacement therapy. 74. Thyroid replacement therapy Antipsychotics Other drug class Other drug class Other drug class Other drug class... Medical History (MHX) Page 10 of 10