Interstitial Lung Disease Evaluation

Interstitial Lung Disease Evaluation Patient Name DOB MRN Encounter Date
Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Yes No
Constitution
Fatigue or Malaise
Fever or chills
History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes
Conjunctivitis
New eye pain
Blurred vision
ENT/mouth
Sore throat
Swollen uvula
Jaw pain
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Respiratory
Dyspnea Chronic, progressive dyspnea over >/= 1 year
Cough Chronic cough with or without phlegm production
Phlegm History of fever, chills, nightsweats, myalgias, arthralgias
Hemoptysis Fatigue, chronic and progressive over same period as dyspnea
Wheeze Increased interstitial markings on >/= 2 radiographs, 1 month apart (not related to renal or heart failure)
History of medication use associated with pulmonary fibrosis
Cardiovascular
Chest pain
Diaphoresis
Ankle edema
Syncope
Palpitations
Gastrointestinal
Nausea or vomiting
Weight changes
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Occupational and Exposure History
Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Aerosolized water Source Hot tub Whirlpool baths High Pressure washings Other
Pets or feathers
Chemicals or fires
Military Experience
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Diarrhea Allergies and Medications
Abdominal pain
Genitourinary
Allergy List reviewed No drug allergies No food allergies History of life threatening allergic response to
Hematuria
Dysuria Medications reviewed Medications reconciled with Nursing Home data
Urethral discharge Past Medical History, Social History and Family History
Musculoskeletal Asthma Diabetes Obstructive Sleep Apnea Other
Myalgias COPD Hepatic Dysfunction Seizure Disorder
Arthralgias Congestive Heart Failure(CHF) HIV/AIDS Thyroid disease Hyper Hypo
Joint swelling Coronary Artery Disease Hypertension Tuberculosis Treatment
Sa
Recent trauma
Skin/Breasts Malignancy
Masses Adrenal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
New skin lesions Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Rash
Neurologic Surgeries CABG Cardiac valve replacement Splenectomy Organ transplant Joint replacement Other
Headaches
Seizures
Muscle weakness ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
Paresthesias Vaccines This patient is current on the following Seasonal Influenza Pneumococcal Varicella Pertussis Tetanus
Endocrinologic
Hair loss Social History / Risk factors
Polydipsia No Yes Tobacco use Number Pack-Years __________
Tremors No Yes Quit tobacco use Quit date __________
Neck pain Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Heme/Lymph Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Bleeding gums
Unusual bruising No Yes Recreational drug use Route Inhalation Injection Ingestion
Swollen lymph nodes No Yes Drug dependence Type Narcotics Benzodiazepines
Allergy/Immunology
Nasal congestion No Yes Alcohol use ___ Drinks per Day Week
Rhinorrhea
Psychologic Family Medical History
Agitation Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Hallucinations CHF Pancreatitis Thrombotic disorder Other
COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Exam WNL = Within Normal Limits
Vitals Constitutional
Height _______ in cm Body habitus WNLCachectic Obese
Grooming WNL Unkempt
Weight _______ lb kg ENT
Within normal limits Edema or erythema present
Nasal mucosa, septum, and turbinates
Temperature _______ C F Dentition and gums Within normal limits
Dental caries Gingivitis
Oropharynx Within normal limits Edema or erythema present Oral ulcers Oral Petechiae
Pulse Rate _______
Rhythm Regular Irregular Mallampati I II III IV
Neck
Blood Pressure ____________ Neck Within normal limits Erythema or scarring consistent with recent or old radiation dermatitis
Sitting Standing Lying Thyroid Within normal limits Thyromegaly Nodules palpable Neck mass _____________________
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Jugular Veins Within normal limits JVD present a, v or cannon a waves present
Oxygen Saturation (Pulse oximetry) Resp
Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
_______ Rest Exercise
Scarring consistent with old, healed radiation dermatitis
Rest Exercise Resp effort Within normal limits Accessory muscle use Intercostal retractions Paradoxic movements
_______
NonInvasive Ventilator
CPAP BiPAP Ins ____
Ventilator
Mode ACSIMVPCPRVC
Exp ____
Date of Intubation ________________

CV
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Chest percussion Within normal limits Dullness to percussion Lt Rt Hyperresonance Lt Rt
Tactile exam Within normal limits Tactile fremitus Increased Decreased ________________________
Auscultation Within normal limits
Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
Clear S1 S2 No murmur, rub or gallop Gallop Rub
Murmur present Systolic Diastolic Grade I II III IV V VI
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Endotracheal Tube Size _____
Peripheral pulses palpable No peripheral edema Peripheral pulses Absent Weak
GI
Tracheostomy Tube Size _____
Abdomen Within normal limits Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
Rate ____ Tidal Vol ____ FiO2 ____ Liver and spleen palpation wnl Unable to palpate Liver Spleen Enlarged Liver Spleen
Lymph (2 areas must be examined)
PEEP level ______
Pressure Support level ______ Lymph node exam wnl Areas examined Neck Axilla Groin Other ___________________
Peak Inspiratory Pressure ______
Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Plateau Pressure ______ Musc
Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present
Sa
ARDS ALI
Gait and station wnl Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
PO2/FiO2 <200 201-300 >300 Extrem
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Labs Skin
No rashes, ecchymoses, nodules, ulcers
\____/ ____ / ____ / ____ / Neuro
/ \ \ \ \
Oriented NOT oriented to Person Time Place
Affect is within normal limits OR Patient appears Agitated Anxious Depressed
Radiology Additional Findings
CXR CT scan Other
Medical Decision Making Impression
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
ER Notes decision maker) understands their medical condition, their prognosis and the consequences of their Code
Old medical records Status decision.
Labs Code Status Patient is a FULL CODE DO NOT ATTEMPT Cardiac Resuscitation DO NOT Intubate
Radiology data
Pathology This patient has advanced health care directives. Their HCPOA is
ECHO
ECG
Stress Test
Pulmonary Function Test
Care Coordinated with
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Patient
HCPOA / Surrogate
PCP
Consultant(s)
Case Management or Social Worker
Pharmacy
Nursing
Recommended Actions
Smoking cessation aids
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
Recommended Diagnostics
pl
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CBC with differential
PT, PTT, INR
Metabolic Panel Basic Complete
HIV
Toxicology screen
PPD
Quantiferon
Sputum Cytology
Sa
Urine for Histoplasma and Legionella

Cultures
Sputum Signature Physician Resident C-FNP PA-C
Bacterial Fungal AFB
Blood
Urine
CSF

Computed Tomography (CT)
Chest Abdomen/Pelvis Head Neck

Positron Emission Tomography (PET)

ECG
ECHO
Bronchoscopy
Transthoracic Needle Biopsy I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA
Cardiothoracic Surgery Consult above and I agree with the assessment and plan as outlined.
Other Supervising Physician Signature

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Interstitial Lung Disease Evaluation

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Interstitial Lung Disease Evaluation Patient Name DOB MRN Encounter Date

Date of Intubation ________________

Urine for Histoplasma and Legionella

Other Supervising Physician Signature

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Interstitial Lung Disease Evaluation

Încărcat de

Informații document

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Interstitial Lung Disease Evaluation

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Interstitial Lung Disease Evaluation Patient Name DOB MRN Encounter Date

Date of Intubation ________________

Urine for Histoplasma and Legionella

Other Supervising Physician Signature

S-ar putea să vă placă și

Urine for Histoplasma and Legionella

Other Supervising Physician Signature