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Patient history

Patient history covers aspects of the patient's condition prior to this heart attack episode that has a bearing on survivability. Remember, patient history is not concerned with the patient's condition during the admission to the hospital or at the time of the heart attack itself. For example, under history you may indicate whether or not the patient has a history of stroke. If the patient actually had a stroke before the heart attack, you would mark the Stroke or TIA box. However, if the patient had a stroke during this hospitalization or concurrent with the heart attack, then you would not mark the Stroke or TIA.

Age

The first data box under patient history is for age. Enter the patient's age at the time of the heart attack hospitalization. For infants under 11 months, enter zero; for all patients, enter the age in whole years.

Angina or prior MI

After the age box, patient history contains a group of four check boxes covering prior medical episodes or conditions. To mark a box, click on it or hit the space bar, depending on your browser. If the patient has a history of angina (chest pain that is relieved by nitroglycerin or rest) or MI (heart attack), check the appropriate box.

Heart failure

If the patient has a history of congestive heart failure (CHF), check the appropriate box. Other terms for CHF include cardiac asthma, congestive cardiomyopathy, and lung edema.

Angioplasty

If the patient had a coronary angioplasty procedure within the five years prior to the heart attack, check the appropriate box. Coronary angioplasty is also referred to as PTCA.

Stroke

If the patient has a history of stroke or transient ischemic attack (TIA), check the appropriate box. Other terms for stroke or TIA include amaurosis fugax, cerebral vascular accident (CVA), subdural hematoma (excluding the condition caused by trauma), brain hemorrhage (excluding the condition caused by trauma), brain infarction, vertebro-basilar insufficiency, brain occlusion, reversible ischemic neurologic disorder (RIND), and brain thrombosis.

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