Pulmonary Arterial Hypertension Evaluation
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Pulmonary Arterial Hypertension Evaluation Date
Chief complaint/Reason for consult
MRN
Start time Stop time Allergies
History of present illness
Allergy list reviewed
Fatigue, weakness Cough Pain Decreased appetite Hemoptysis Weight loss Calcinosis Raynaud’s Esophageal dysfunction Sclerodactyly Telangiectasias Dyspnea Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest
No drug allergies No food allergies
www.e-medtools.com
Medications
Medication list reviewed Med list reconciled with
Nursing Home, Skilled Nursing facility or Rehab facility med list 46
www.e-medtools.com
Social History
Review of Systems
Tobacco use
See HPI WNL
____ Packs x ____ Yrs
Quit
Chronic exposure to second hand smoke 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
www.e-medtools.com
Constitutional Fatigue, malaise, change in appetite Eyes Vision changes, new pain, scotomas ENT/mouth Nose bleeds, dental Caries, dental abscesses, jaw pain Resp Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness CV Chest pain, diaphoresis, ankle edema, PND, syncope www.e-medtools.com GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena GU Change in urinary habits, hematuria, dysuria Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling or redness Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun exposure Neuro Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor Endo Hair loss, polydipsia, polyuria, gynecomastia Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes www.e-medtools.com Allergy/Immun Sinus probs, recurrent infections, anaphylaxis Psych Mood changes, agitation, psychosis, delirium, dementia
Recreational drug use Inhalational Injectable Ingestible Drug dependence
Occupational History
Family Medical History
Past Medical and Surgical History
AV Malformations Pulmonary Hypertension Rheumatoid Arthritis Scleroderma Systemic Lupus Erythematosus Malignancy
Asthma Appetite Suppressant Use Neuromuscular weakness Bronchiectasis AV Malformations Occupational exposures Cryptogenic Organizing Pneumonia (BOOP) Cerebral Artery Disease Peripheral Artery Disease COPD Congenital Heart Defects Scleroderma Cystic Fibrosis Left to Right Shunt Seizure Disorder Histiocytosis Atrial Septal Defect Sjogren Obstructive Sleep Apnea Ventricular Septal Defect Systemic Lupus Erythematosus CPAP BiPAP Patent Ductus Arteriosus Renal Dysfunction Tuberculosis Congestive Heart Failure Rheumatoid Arthritis Pulmonary Arterial Hypertension Coronary Artery Disease Thrombotic Disease Pulmonary fibrosis Dermatomyositis/Polymyositis Thyroid Disease Pulmonary Thromboembolic Disease Diabetes Malignancy Pulmonary Venoocclusive Disease Diastolic Dysfunction Breast Sarcoidosis Nocturnal GERD Colon Tuberculosis Hepatic Dysfunction Lung Surgeries HIV/AIDS Melanoma Hypertension Prostate Inflammatory Bowel Disease Renal cell Mitral Stenosis or Regurgitation Testicular Mixed Connective Tissue Disorder Thyroid Myocarditis/Pericarditis Other
Narcotics Benzodiazepines
Breast Colon Lung Melanoma Prostate Renal cell Testicular Thyroid Other
©MB and RR 2006, 2007
www.e-medtools.com
Revised 26Sep07
Pulmonary Arterial Hypertension Evaluation Vitals
Exam
✔ Checked box indicates findings are within normal limits
Weight
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 CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema www.e-medtools.com GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph No lymphadenopathy Musc Tone Gait Extrem No clubbing No cyanosis www.e-medtools.com Skin No rashes, ecchymoses, nodules, ulcers Neuro Oriented Affect General
BMI
ENT Temperature BP Pulse Sats At Rest With Activity CVP Cardiac Output Urine Output Last 24 hours
Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Last 8 hours
www.e-medtools.com
Labs/Tests
Impression and Plan
LFTs Hepatitis Panel HIV TSH CBC BMP D-dimer ESR Phospholipid Ab RF dsDNA Ab ssDNA Ab Centromere Ab Topoisomerase I Ab (Scl-70) U1RNP Ab Jo-1 Ab
Schedule Patient For
Pulmonary Function Testing Methacholine Challenge 6 Minutewww.e-medtools.com Walk Test CXR Chest CT with contrast V/Q Scan ECHO With Bubble study www.e-medtools.com Assess PA pressures Cardiopulmonary Stress Test Sleep Study Bronchoscopy www.e-medtools.com Pneumococcal vaccine Influenza vaccine
Signature Patient has completed advanced health care directives47
Code Status
Full code Do Not Attempt Resuscitation
Health Care Power Of Attorney is
Continuous home oxygen Tx Flow rate ____________L/min Concentrator Tank with conservation valve Nasal cannula with reservoir Portable tank Gas Liquid Supplemental oxygen therapy during air travel Flow rate ____________L/min Home CPAP BiPAP Flow rate ____________L/min Heater and humidifier Mask type Nasal Oronasal Face ©MB and RR 2006, 2007
Revised 26Sep07
Chief complaint/Reason for consult
MRN
Start time Stop time Allergies
History of present illness
Allergy list reviewed
Fatigue, weakness Cough Pain Decreased appetite Hemoptysis Weight loss Calcinosis Raynaud’s Esophageal dysfunction Sclerodactyly Telangiectasias Dyspnea Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest
No drug allergies No food allergies
www.e-medtools.com
Medications
Medication list reviewed Med list reconciled with
Nursing Home, Skilled Nursing facility or Rehab facility med list 46
www.e-medtools.com
Social History
Review of Systems
Tobacco use
See HPI WNL
____ Packs x ____ Yrs
Quit
Chronic exposure to second hand smoke 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
www.e-medtools.com
Constitutional Fatigue, malaise, change in appetite Eyes Vision changes, new pain, scotomas ENT/mouth Nose bleeds, dental Caries, dental abscesses, jaw pain Resp Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness CV Chest pain, diaphoresis, ankle edema, PND, syncope www.e-medtools.com GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena GU Change in urinary habits, hematuria, dysuria Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling or redness Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun exposure Neuro Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor Endo Hair loss, polydipsia, polyuria, gynecomastia Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes www.e-medtools.com Allergy/Immun Sinus probs, recurrent infections, anaphylaxis Psych Mood changes, agitation, psychosis, delirium, dementia
Recreational drug use Inhalational Injectable Ingestible Drug dependence
Occupational History
Family Medical History
Past Medical and Surgical History
AV Malformations Pulmonary Hypertension Rheumatoid Arthritis Scleroderma Systemic Lupus Erythematosus Malignancy
Asthma Appetite Suppressant Use Neuromuscular weakness Bronchiectasis AV Malformations Occupational exposures Cryptogenic Organizing Pneumonia (BOOP) Cerebral Artery Disease Peripheral Artery Disease COPD Congenital Heart Defects Scleroderma Cystic Fibrosis Left to Right Shunt Seizure Disorder Histiocytosis Atrial Septal Defect Sjogren Obstructive Sleep Apnea Ventricular Septal Defect Systemic Lupus Erythematosus CPAP BiPAP Patent Ductus Arteriosus Renal Dysfunction Tuberculosis Congestive Heart Failure Rheumatoid Arthritis Pulmonary Arterial Hypertension Coronary Artery Disease Thrombotic Disease Pulmonary fibrosis Dermatomyositis/Polymyositis Thyroid Disease Pulmonary Thromboembolic Disease Diabetes Malignancy Pulmonary Venoocclusive Disease Diastolic Dysfunction Breast Sarcoidosis Nocturnal GERD Colon Tuberculosis Hepatic Dysfunction Lung Surgeries HIV/AIDS Melanoma Hypertension Prostate Inflammatory Bowel Disease Renal cell Mitral Stenosis or Regurgitation Testicular Mixed Connective Tissue Disorder Thyroid Myocarditis/Pericarditis Other
Narcotics Benzodiazepines
Breast Colon Lung Melanoma Prostate Renal cell Testicular Thyroid Other
©MB and RR 2006, 2007
www.e-medtools.com
Revised 26Sep07
Pulmonary Arterial Hypertension Evaluation Vitals
Exam
✔ Checked box indicates findings are within normal limits
Weight
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 CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema www.e-medtools.com GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph No lymphadenopathy Musc Tone Gait Extrem No clubbing No cyanosis www.e-medtools.com Skin No rashes, ecchymoses, nodules, ulcers Neuro Oriented Affect General
BMI
ENT Temperature BP Pulse Sats At Rest With Activity CVP Cardiac Output Urine Output Last 24 hours
Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Last 8 hours
www.e-medtools.com
Labs/Tests
Impression and Plan
LFTs Hepatitis Panel HIV TSH CBC BMP D-dimer ESR Phospholipid Ab RF dsDNA Ab ssDNA Ab Centromere Ab Topoisomerase I Ab (Scl-70) U1RNP Ab Jo-1 Ab
Schedule Patient For
Pulmonary Function Testing Methacholine Challenge 6 Minutewww.e-medtools.com Walk Test CXR Chest CT with contrast V/Q Scan ECHO With Bubble study www.e-medtools.com Assess PA pressures Cardiopulmonary Stress Test Sleep Study Bronchoscopy www.e-medtools.com Pneumococcal vaccine Influenza vaccine
Signature Patient has completed advanced health care directives47
Code Status
Full code Do Not Attempt Resuscitation
Health Care Power Of Attorney is
Continuous home oxygen Tx Flow rate ____________L/min Concentrator Tank with conservation valve Nasal cannula with reservoir Portable tank Gas Liquid Supplemental oxygen therapy during air travel Flow rate ____________L/min Home CPAP BiPAP Flow rate ____________L/min Heater and humidifier Mask type Nasal Oronasal Face ©MB and RR 2006, 2007
Revised 26Sep07
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