 Monitoring The Patients’ File:
A Simulation The various steps described in this presentation are all geared toward one central task: monitoring the patient’s file. As this is also the only task to take up real time from the daily routine, a simulation seems in order....
H. Heart Male; Age –73; I.D# 1111 |
Cardiovascular Risk Assessment |
A
73-Year old male with ischemic heart disease with stable angina pectoris,
and an anterior wall myocardial infarction 7 years ago.
Risk Factors:
- Hypertension with blood pressure recordings of 150/90 and 160/90
during past month.
- Diabetes mellitus with a fasting serum glucose
of 132 mg/dl and a Hemoglobin A 1C level of 7%.
- Not overweight.
- Regular physical activity.
- Non-smoker.
- Ldl-cholesterol
level of 120 mg/dl, three months after dietary consultation.
-
Pharmacological therapy includes aspirin, an ace-inhibitor and a
beta-blocker.
Operative
Conclusions:
1) Increase enalapril toward blood pressure goal of 130/80 if well
tolerated.
2) Commence therapy with statin toward Ldl-cholesterol
goal of < 100 mg/dl.
Add diagnosis of dyslipidemia to problem-list. |
|
Clinical Data | |
Physical Data | |
Lab Results | |
Medications | |
Risk Status |
This is a simulation of Mr. Hearts’ Electronic Medical Record.
Mr. Heart is 73 years old and has ischemic heart disease, with stable angina pectoris. He suffered an anterior wall myocardial infarction in 1995. He has diabetes mellitus and hypertension. Mr. Heart also has a right inguinal hernia, and benign prostatic hypertrophy. Data concerning
Physical Data, Lab Results and Medications can be accessed via the links on the right side of the screen.
This is followed by a summary of Mr. Hearts’ cardiovascular
Risk Status, including operative conclusions. |