Cardiac Symptom Template Guide 2015 V1

Transcription

1 Cardiac Symptom Template Guide 2015 V1 1

2 Template Control Page Cardiac Symptom Template Title Cardiac Symptom CEG TEST Author CEG Version 1 Descriptor Helps support the cardiac project funded by UCLP/NCCG DOCUMENT MANAGEMENT REVISION HISTORY Version Date Summary of Changes Date sent to EMIS 1 March 2015 New Template AUTHORISATION Reviewed by Jayne Callaghan Approved by Dr John Robson Library Items, protocols and concepts used by this template Library Items Concepts MI/Angina CEG HF001 - Patients on Heart Failure Register STIA001 - Patients on Stroke / TIA Register Aneurysm CEG AF001 - Patients on AF Register PAD001 - Patients with Peripheral Arterial Disease DM001(W)/DM017(E) - Patients on Diabetic Register COPD1 - Patients on COPD Register HYP001 - Patients on hypertension register Hyperlipidaemia CEG Lupus CEG Rheumatoid CEG HIV Positive CEG Pulmonary Embolism CEG 2

3 Cardiac Symptom Template Guide The template includes coded data entry for Cardiac Symptoms for referral through the Newham Care Pathway??? John need more details. Cardiac Symptoms include the following: Chest Pain Breathlessness Palpitations Syncope Main Page Prompt Code What does this prompt mean? EMIS WEB Consult. Section This template is to be used for patients being assessed for the commonest cardiac symptoms:- Chest Pain Breathlessness Syncope/Dizziness Palpitations Please use the pages along the left hand side to record examination (including FH & lab results) and symptoms. Use the appropriate referral pathway including the new Integrated Cardiac Care Service when it is available. Cardiac Symptom 18ZZ Default tick box Template Below is a list of patient's relevant latest Diagnosis MI/Angina Visibility Rule: MI/Angina CEG MI/Angina Last coded entry Heart Failure Visibility Rule: HF001 - Patients on Heart Failure Register Heart Failure Last coded entry Stroke/TIA Visibility Rule: STIA001 - Patients on Stroke / TIA Register Stroke/TIA Last coded entry Aneurysm Visibility Rule: Aneurysm CEG Aneurysm G71% Last coded entry Atrial Fibrillation Visibility Rule: AF001 - Patients on AF Register Atrial Fibrillation Last coded entry Vascular Disease Visibility Rule: PAD001 - Patients with Peripheral Arterial Disease Vascular Disease Last coded entry Diabetes Visibility Rule: DM001(W)/DM017(E) - Patients on Diabetic Register Diabetes Last coded entry COPD Visibility Rule: COPD1 - Patients on COPD Register CODP Last coded entry Hypertension Visibility Rule: HYP001 - Patients on hypertension register Hypertension Last coded entry Hyperlipidaemia Visibility Rule: Hyperlipidaemia CEG 3

4 Familial Hypercholesterol aemia/hyperlipid aemia Last coded entry Lupus Visibility Rule: Lupus CEG Lupus N000 Last coded entry Rheumatoid Visibility Rule: Rheumatoid CEG Rheumatoid N040 Last coded entry HIV Positive Visibility Rule: HIV Positive CEG HIV Positive 43C3 / A788 Last coded entry Pulmonary Embolism Visibility Rule: Pulmonary Embolism CEG Pulmonary Embolism Last coded entry Symptom/ Page rmation 'Please tick only relevant symptoms' Chest Pain Constricting discomfort in front chest Location - Central Chest Pain 1822 Tick box Text line: Duration of pain Radiation (Jaw, 18ZZ Tick box neck or arm pain) Free Text Provocationchest pain on exertion Chest pain relieved by glyceryl trinitrate Atypical chest pain 182A EMISNQC H692 Tick box Text line Tick Box Free text Other non-specific chest pain 1828 Tick box Text box Click here for PISA score Hyperlink Once the PISA Score is calculated you will need to free text this on the referral letter. SPECIALIST REFERRAL Rapid Access Chest Pain Clinic: New Onset/Stable chest pain Cardiac Referral (Routine or Urgent): Possible worsening of known Ischaemic Heart Disease A&E referral: Crescendo Angina or Suspected ACS Breathlessness NYHA classification info Community Clinic (ICCS) - Not suitable for Chest Pain New York Heart Association Heart failure symptom classification: Class I (Asymptomatic): Ordinary physical activity does not cause undue fatigue, 4 Commented [FW1]: This section matches what is being used in the Heart Failure template, are we going to delete it?

5 NYHA Classification dyspnoea or palpitations. Class II (Mild Heart Failure): Patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitations, dyspnoea or angina. Class III (Moderate Heart Failure): Although comfortable at rest, marked limitation of physical activity. Class IV (Severe Heart Failure): Symptoms at rest. Inability to carry out any physical activity without discomfort. NYHA Class I (662f) NYHA Class II (662g) NYHA Class III (662h) NYHA Class IV (662i) Assessment SOB 1739 Tick box Worsening 183A Tick box peripheral oedema Text box SPECIALIST REFERRAL HEART FAILURE SUSPECTED and if any of the following are present: Cardiac Referral (URGENT) - of previous MI, or if the BNP is over Cardiac Referral (ROUTINE) - If the BNP is between No Referral - If the BNP is less than 400 heart failure is unlikely. Community Clinic (ICCS) - If the patient remains symptomatic or has clinical features of heart failure, in spite of being optimised on beta blockers, ACE inhibitors and diuretics. Cardiac Related Cardiac related dizziness/syncope Potential 'triggers': None, heat, noxious stimuli, posture (especially on standing), vagal stimuli (urinating, coughing, vomiting) exercise others Enter 'trigger' in free text below: Syncope Trigger 147A Tick box Allow Text Description of attack How long did the dizziness/syncope episode last? Free text Had a collapse (1B65) Felt faint (1B68) Loss of consciousness No loss of consciousness (1B61) No syncope No consciousness disturbance (1B61) There is no effective treatment for the most common cardiac causes of dizziness and syncope. Simple reassurance is therefore appropriate for patients with: 5 Commented [FW2]: Can you find me a code please Commented [FW3]: Can you find me a code please

6 Postural hypotension: attacks provoked by standing from lying or sitting position (with or without measurable drops in blood pressure) - particularly in old people Vasovagal syncope: often a history going back several years of fainting attacks - may be triggered by noxious or vagal stimuli including cough or urinating. Prodromal symptoms are common allowing attacks to be aborted by lying down. SPECIALIST REFERRAL How long did dizziness/syncope episode last? Consider specialist referral if any of the following apply: Attacks worsening despite reassurance Attacks triggered by exertion or rapid palpitation. Family of premature (<70) sudden death in 1st degree relatives Attacks result in traumatic injury Resting bradycardia (<50bpm) Signs of aortic stenosis Free text box Palpitations Palpitations 181 Tick box Reassure appropriately if: Ectopic beats: Brief fluttering sensations in chest occuring without provocation and associated with pauses or firm thumps - Particularly in young people. Physiological tachycardia: normal increases in heart rate during exercise or stress Panic attacks: Unprovoked attacks of palpitations, air hunger and light headedness resolving spontaneously SPECIALIST REFERRAL Consider specialist referral if any of the following apply: Palpitations remain troublesome despite reassurance Age >60 Family history of premature (<70) sudden death in 1st degree relatives (parents/sibs) of ACS, CCF or Valvular heart disease Associated chest pain, SOB or presyncope Rapid palpitations, regular or irregular (rate >110 BMP) Prolonged attacks of irregular palpitations. Family FH: IHD<60 First Degree Relative Smoking Status Smoking Status Picking list FH:IHD<60 (first degree relative) (12C2) No FH: IHD (1226) Text line: Family Member Never smoked tobacco (1371) Ex Smoker (137S) 6

7 Smoking cessation advice Cigarette smoker (137P) Rolls own cigarettes (137M) Pipe smoker (137H) 8CAL Smoking 8CAL Tick box cessation advice given Blood Pressure Value Pulse Rate 242 Value Pulse Rhythm O/E pulse rhythm regular (2431) O/E irregular pulse (2435) O/E pulse irregularly irreg (2432) Chest wall pain 182C Tick box Pulmonary 23E1 Tick box Oedema Height 229 Enter the value for height Weight 22A Enter the value for weight Body Mass Index 22K Automatically calculated by EMIS JVP raised 2483 Tick box Oedema Ankle oedema (22C2) Leg oedema (22C4) Ascites NOS (25OZ) O/E Sacral Oedema (22C7) O/E - oedema not present (22C1) Pick more than one O/E Pulmonary 23E1 Oedema O/E Chest Lung sounds O/E O/E Crackles (23D) Coarse crepitations (23D3) O/E Fine Crepitations (23D4) O/E Breath sounds normal (23B1) O/E rate of 235 Value respiration Laterality of lung sounds PaO2 level 44Y4 Enter value Result LAB Results/Investigations Page MI Diagnosis Visibility Rule: MI/Angina CEG NT-proBNP 44AP Enter Value Result TEST Request: NT-proBNP in patients with suspected CCF but no history of MI. Biochemistry - N terminal pro-brain natriuretic peptide level) - This blood test is available in EMIS. 7

8 If you suspect Heart Failure in a patient who previously had MI there is no need for BNP - Instead 2 week wait referral to cardiology (or ICCS when available.) Serum Cholesterol 44P Last coded entry Result Serum HDL 44P5 Last coded entry Result Cholesterol level Serum LDL 44P6 Last coded entry Cholesterol HbA1c (IFCC) 42W5 Last coded entry Result Hb 423 Last coded entry Result egfr 451E Last coded entry Result Serum Creatinine 44J3 Last coded entry Result Serum Potassium 44I4 Last coded entry Result Sodium 44h1 Last coded entry Result ALT 44GB Last coded entry Result Serum Triglycerides 44Q Last coded entry Result Serum Creatinine 44J3 Last coded entry Result Sodium 44h1 Last coded entry Result Serum Potassium 44I4 Last coded entry Result ALT 44GB Last coded entry Result LDL cholesterol 44P6 Last coded entry Result Qrisk2 38DP Last coded entry Result Please do IN HOUSE ECG ECG Done 321B Last coded entry ECG Result ECG normal Result ECG abnormal Referral Page If you have a complex patient, consider referral to a Cardiac Sub-speciality clinic at Barts Health: Heart failure clinic Hypertension clinic High Risk clinic Arrhythmia clinic Heart muscle disease clinic Grown Up Congenital Heart Disease clinic Referral Referral to rapid access chest pain clinic (8HTJ) Cardiology referral (8H44) Ref to A &E Dept (8HC1) Referral to cardiology special interest general practitioner (8H4R) Follow up 8HBZ Prompt for date New cardiac symptom template Survey Hyperlink Follow up 8HBZ Date prompt Free text Please fill in the survey below. It should not take longer than 2 minutes of your time and your comments are extremely valuable. Thank you. 8