Pleural Effusion Evaluation
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Pleural Effusion Evaluation MRN
Date
Allergies
Chief complaint/Reason for consult
Start time
Medications
History of present illness
Stop time
www.e-medtools.com
Pleuritic chest pain present www.e-medtools.com Dyspnea or cough Peripheral edema Orthopnea or PND Decreased exercise tolerance Recent fever, chills or nightsweats
Recent severe emesis or esophageal dilatation Recent MI or cardiothoracic surgery CHF, ESRD on HD, SLE, RA, Sarcoidosis History of asbestos exposure History of malignancy
Drugs associated with pleural effusion include, but are not limited to: bromocriptine, cyclophosphamide, dantrolene, isotretinoin, mesalamine, methotrexate, mitomycin, nitrofurantoin, practolol, procarbazine
www.e-medtools.com
Social History
Review of Systems
Tobacco use
See HPI WNL
____ Packs x ____ Yrs
Quit
Daily, occasional and ex-smokers are more likely to be hazardous drinkers
Alcohol use ______ Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines)
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day
Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite Eyes Vision changes, New pain, Scotomas www.e-medtools.com ENT/mouth Nose bleeds, dental caries, dental abscesses, jaw pain Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea CV Chest pain, diaphoresis, ankle edema, PND, syncope GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena GU Change in urinary habits, hematuria, dysuria Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun www.e-medtools.com Neuro Seizures, episodic or chronic muscle weakness Endo Hair loss, polydipsia Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes Allergy/Immun Sinus probs, recurrent infections Psych Mood changes, agitation, psychosis, delirium, dementia
Recreational drug use
Notes
Family Medical History
Past Medical and Surgical History
Congestive Heart Failure Coronary Artery Disease Malignancy Pancreatitis Renal Dysfunction Thyroid Disease
www.e-medtools.com
Asthma Cerebral Artery Disease Bronchiectasis Congestive Heart Failure COPD Coronary Artery Disease COP (BOOP) Diabetes Cystic Fibrosis GERD Histiocytosis Hepatic Dysfunction Tuberculosis HIV/AIDS PAH Hypertension Sarcoidosis Inflam bowel disease Tuberculosis Malignancy
Notes
©MB and RR 2006, 2007
Revised 24April07
Neuromuscular weakness Occupational exposures Pancreatitis Peripheral Artery Disease Scleroderma Seizure Disorder Sjogren Renal Dysfunction Rheumatoid arthritis Thrombotic Disease Thyroid Disease
Chemotherapy Colonoscopy ECHO/Stress Test Mammogram PFTs PapSmear Prior Intubations Radiation exposure Sleep Study Steroid use
Pleural Effusion Evaluation Vitals _____ _____
Exam Weight Height
_____ Temperature ___________ BP Sitting ___________ BP Standing Sats Rest
Pulse
_____
_____
Exercise 50 feet _____
_____
100 feet
_____
_____
Alert Nasal mucosa Dentition Oropharynx Mallampati I II III IV Neck Normal to palpation Thyroid No JVD Resp Clear to auscultation Dullness to percussion No respiratory distress No chest wall defects Decreased fremitus Bronchial breath sounds Absence of intercostal respiratory retractions Egophony (E to A change) CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph No lymphadenopathy Musc Tone Gait Extrem No clubbing No cyanosis Skin www.e-medtools.com No rashes, ecchymoses, nodules, ulcers Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Affect General
ENT
Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Labs/Tests
Impression and Plan www.e-medtools.com
CXR (PA, lateral, lateral decubitus) CT of chest
DDx includes, but is not limited to: Pulmonary embolism, Tuberculous pleurisy, Infection, hepatitis, esophageal rupture of any cause or recent sclerotherapy, malignancy, pancreatitis, congestive heart failure, renal failure, hemothorax, uremic pleurisy, sarcoidosis, post-cardiac injury syndrome or coronary artery bypass graft surgery, ARDS, lupus, rheumatoid pleurisy, MCTD, hypothyroidism, urinothorax, SVC obstruction, trapped lung, hypoalbuminema, cirrhosis, atelectasis, pericarditis
(PE protocol if PE suspected)
PET scan MRI Thoracentesis Pleural fluid Glucose LDH, include serum level pH Protein, include serum level Cell count with differential (all suspected exudates)
Cultures: bacterial, fungal, AFB (all suspected exudates) Cytology (suspected exudates) Adenosine deaminase (for TB) Amylase (for suspected pancreatitis or ruptured esophagus) ANA, RF (for suspected autoimmune disease)
Flow cytometry
(for suspected lymphoma)
Hematocrit (for bloody effusion) Pleural biopsy (for suspected TB or malignancy)
Triglyceride, cholesterol levels (for suspected chylothorax or pseudochylothorax) Urea (for suspected urinothorax)
Exudate if: Pleural:serum protein >0.5 Pleural:serum LDH >0.45 pleural LDH >2/3 upper limit normal for serum If patient history of diuretic use: Serum -- pleural protein = <3.1 g/dL suggests exudate Pleural LDH of >1000 suggests empyema, malignancy, rheumatoid lung effusion or paragonimiasis
©MB and RR 2006, 2007
Imperative rule outs: PE and tuberculous pleurisy => due to increased morbidity if left undiagnosed
www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com Patient has completed advanced health care directives47 HCPOA is
Signature
Revised 24April07
Date
Allergies
Chief complaint/Reason for consult
Start time
Medications
History of present illness
Stop time
www.e-medtools.com
Pleuritic chest pain present www.e-medtools.com Dyspnea or cough Peripheral edema Orthopnea or PND Decreased exercise tolerance Recent fever, chills or nightsweats
Recent severe emesis or esophageal dilatation Recent MI or cardiothoracic surgery CHF, ESRD on HD, SLE, RA, Sarcoidosis History of asbestos exposure History of malignancy
Drugs associated with pleural effusion include, but are not limited to: bromocriptine, cyclophosphamide, dantrolene, isotretinoin, mesalamine, methotrexate, mitomycin, nitrofurantoin, practolol, procarbazine
www.e-medtools.com
Social History
Review of Systems
Tobacco use
See HPI WNL
____ Packs x ____ Yrs
Quit
Daily, occasional and ex-smokers are more likely to be hazardous drinkers
Alcohol use ______ Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines)
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day
Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite Eyes Vision changes, New pain, Scotomas www.e-medtools.com ENT/mouth Nose bleeds, dental caries, dental abscesses, jaw pain Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea CV Chest pain, diaphoresis, ankle edema, PND, syncope GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena GU Change in urinary habits, hematuria, dysuria Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun www.e-medtools.com Neuro Seizures, episodic or chronic muscle weakness Endo Hair loss, polydipsia Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes Allergy/Immun Sinus probs, recurrent infections Psych Mood changes, agitation, psychosis, delirium, dementia
Recreational drug use
Notes
Family Medical History
Past Medical and Surgical History
Congestive Heart Failure Coronary Artery Disease Malignancy Pancreatitis Renal Dysfunction Thyroid Disease
www.e-medtools.com
Asthma Cerebral Artery Disease Bronchiectasis Congestive Heart Failure COPD Coronary Artery Disease COP (BOOP) Diabetes Cystic Fibrosis GERD Histiocytosis Hepatic Dysfunction Tuberculosis HIV/AIDS PAH Hypertension Sarcoidosis Inflam bowel disease Tuberculosis Malignancy
Notes
©MB and RR 2006, 2007
Revised 24April07
Neuromuscular weakness Occupational exposures Pancreatitis Peripheral Artery Disease Scleroderma Seizure Disorder Sjogren Renal Dysfunction Rheumatoid arthritis Thrombotic Disease Thyroid Disease
Chemotherapy Colonoscopy ECHO/Stress Test Mammogram PFTs PapSmear Prior Intubations Radiation exposure Sleep Study Steroid use
Pleural Effusion Evaluation Vitals _____ _____
Exam Weight Height
_____ Temperature ___________ BP Sitting ___________ BP Standing Sats Rest
Pulse
_____
_____
Exercise 50 feet _____
_____
100 feet
_____
_____
Alert Nasal mucosa Dentition Oropharynx Mallampati I II III IV Neck Normal to palpation Thyroid No JVD Resp Clear to auscultation Dullness to percussion No respiratory distress No chest wall defects Decreased fremitus Bronchial breath sounds Absence of intercostal respiratory retractions Egophony (E to A change) CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph No lymphadenopathy Musc Tone Gait Extrem No clubbing No cyanosis Skin www.e-medtools.com No rashes, ecchymoses, nodules, ulcers Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Affect General
ENT
Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Labs/Tests
Impression and Plan www.e-medtools.com
CXR (PA, lateral, lateral decubitus) CT of chest
DDx includes, but is not limited to: Pulmonary embolism, Tuberculous pleurisy, Infection, hepatitis, esophageal rupture of any cause or recent sclerotherapy, malignancy, pancreatitis, congestive heart failure, renal failure, hemothorax, uremic pleurisy, sarcoidosis, post-cardiac injury syndrome or coronary artery bypass graft surgery, ARDS, lupus, rheumatoid pleurisy, MCTD, hypothyroidism, urinothorax, SVC obstruction, trapped lung, hypoalbuminema, cirrhosis, atelectasis, pericarditis
(PE protocol if PE suspected)
PET scan MRI Thoracentesis Pleural fluid Glucose LDH, include serum level pH Protein, include serum level Cell count with differential (all suspected exudates)
Cultures: bacterial, fungal, AFB (all suspected exudates) Cytology (suspected exudates) Adenosine deaminase (for TB) Amylase (for suspected pancreatitis or ruptured esophagus) ANA, RF (for suspected autoimmune disease)
Flow cytometry
(for suspected lymphoma)
Hematocrit (for bloody effusion) Pleural biopsy (for suspected TB or malignancy)
Triglyceride, cholesterol levels (for suspected chylothorax or pseudochylothorax) Urea (for suspected urinothorax)
Exudate if: Pleural:serum protein >0.5 Pleural:serum LDH >0.45 pleural LDH >2/3 upper limit normal for serum If patient history of diuretic use: Serum -- pleural protein = <3.1 g/dL suggests exudate Pleural LDH of >1000 suggests empyema, malignancy, rheumatoid lung effusion or paragonimiasis
©MB and RR 2006, 2007
Imperative rule outs: PE and tuberculous pleurisy => due to increased morbidity if left undiagnosed
www.e-medtools.com www.e-medtools.com www.e-medtools.com www.e-medtools.com Patient has completed advanced health care directives47 HCPOA is
Signature
Revised 24April07
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