CD Document JSON Generator

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ETD Chest Pain Clerking Note

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HISTORY

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Onset Of Worst / Continuous Chest Pain

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Duration Of Worst / Continuous Chest Pain

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Character Of Chest Pain

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Pain Relief

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Associated Symptoms

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Risk Factor

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Past Medical/Surgical History

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Drugs History

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Personal And Family History

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Menstrual History

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Menarche Age

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LMP

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Unsure Of Date

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POA

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Pregnant

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Menopause Age

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Remarks

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PHYSICAL EXAMINATION - CHEST PAIN

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General Condition

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Hydration Status

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Peripherals

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Evidence Of Failure

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Neck Vein

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Vital Signs & Other Observations

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Pupils

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Cardiovascular System (CVS)

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Apex Beat

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Heave

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Thrill

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Heart Sound

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Murmur

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Radial Delay

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Radial Remoral Delay

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Cns

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Lethargy

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Restlessness

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Mental Status

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Neck Stiffness

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Cranial Nerve

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Peripheral Nerve

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Cerebellar

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Abdomen

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Inspection

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Palpation

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Auscultation

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Bowel Sound

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Respiratory

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Tracheal Deviation

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Auscultation

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Percussion

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Skin And Lymph Node

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Unilateral Leg Swelling

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Genitourinary

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INVESTIGATION

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ECG Finding

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Classification of ECG Abnormalities

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Type Of Abnormalities

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Location Of Abnormalities

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Bed Side Echocardiography

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TIMI Risk Score

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Kilip Score

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DIAGNOSIS

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MANAGEMENT

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REPERFUSION THERAPY / MANAGEMENT

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Contraindication For Reperfusion Strategy

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Thrombolysis

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Absolute Contraindication

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Relative Contraindication

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Primary PCI

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Contraindication

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Choice Of Reperfusion

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EMERGENCY DEPARTMENT TO BE COMPLETED BY HUB

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Arrival Time In ETD

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Arrival Blood Pressure

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Intubated On Arrival

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Inotropic Support

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Attempted Cpr

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Case Discussed Prior To

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CATH LAB TO BE COMPLETED BY HUB

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Arrival Time In Cath Lab

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Kilip Score

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Cpr On Table

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Device Cross Time

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Comments

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Intubated On Arrival

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Additional Advise

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Balloon Time

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Any Delay in Door To Balloon time in ( > 120 mins )

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SIGNATURES

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