Pulmonary Clinic History And Physical
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Pulmonary Clinic History And Physical as PDF for free.
More details
- Words: 1,085
- Pages: 3
www.e-medtools.com Outpatient Pulmonary Evaluation Review of Systems Review of Systems Constitution Fatigue or Malaise Fever or chills Appetite changes Eyes Conjunctivitis New eye pain Blurred vision ENT/mouth Sore throat Swollen uvula Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Pleuritic Symptoms Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rash Neurologic Headaches Seizures Numbness Paresthesias Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Nasal congestion Rhinorrhea Psychologic Agitation Hallucinations
©MB and RR 2006-2010
Patient Name
DOB
Chief complaint/Reason for consult Yes
No
MRN
Start Time
Stop Time
Date
History of Present Illness
www.e-medtools.com
Allergies and Medications
Allergy List reviewed No drug allergies No food allergies Medications reviewed Medications reconciled with Nursing Home data
www.e-medtools.com
Past Medical, Family Social History (PFSH) Past Medical History
Asthma COPD Congestive Heart Failure(CHF) Coronary Artery Disease
Diabetes Hepatic Dysfunction HIV/AIDS Hypertension
Obstructive Sleep Apnea Other Seizure Disorder Thyroid disease Hyper Hypo Tuberculosis
No Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid Treatment Surgical Resection Chemotherapy Radiation Malignancy
www.e-medtools.com
ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers Vaccines This patient is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella Tetanus Surgeries
Appendectomy Arterial bypass Coronary Artery Bypass Cardiac valve repair or replace Carotid Endarterectomy
Cholecystectomy Colon resection Hysterectomy Nephrectomy Splenectomy
Pacemaker Defibrillator
Organ transplant Other
Hip replacement Knee replacement
Social History Risk factors
Denies Yes ■ Denies Yes
Tobacco use Number Pack-Years _________ Quit tobacco use Quit date _________ ■ Willingness to Quit Unwilling Considering Quit but resumed Within 1 month Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade
www.e-medtools.com
Denies Yes Denies Yes
Recreational drug use Route Inhalation Injection Ingestion Drug dependence Type Narcotics Benzodiazepines
Denies Yes
Alcohol use ___ Drinks per Day Week
Buproprion or nortriptyline
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 Hot tub or Jacuzzi High Pressure washings Pets or feathers Chemicals or fires
www.e-medtools.com
Military HIstory Family History
Asthma Coronary Artery Disease CHF Pancreatitis COPD Peripheral Artery Disease [email protected]
Renal Dysfunction Thrombotic disorder Thyroid Disease
Revised 3Feb2010
Malignancy Other
Health Care Provider Signature
www.e-medtools.com Outpatient Pulmonary Evaluation
Patient Name
DOB
MRN
Exam Labs \____/ / \
____ / ____ / ____ / \ \ \
Constitutional WNL = Within Normal Limits Height _______ in cm Weight _______
lb kg Temperature _____
Respiratory Rate _______ Pulse Rate _______ AND Rhythm Regular Irregular www.e-medtools.com Blood Pressure Sitting __________ OR Standing __________ OR Lying __________
Optional Sats _____ % x
Body habitus WNL
x
Grooming
ENT x x x
Cachectic Obese WNL Unkempt
WNL Edema or erythema present Gingivitis Oropharynx WNL Edema or erythema present Oral ulcers Oral Petechiae Mallampati I II III IV Nasal mucosa, septum, and turbinates
Dentition and gums WNL Dental caries
www.e-medtools.com Neck x
Radiology
x
CXR CT/Chest Other
WNL Erythema or scarring consistent with recent or old radiation dermatitis Nodules palpable Neck mass Jugular Veins WNL JVD present a, v or cannon a waves present Neck
Thyroid WNL Thyromegaly
x Respiratory x
Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis Old, healed radiation dermatitis Prior surgery Trauma Other Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements Chest percussion WNL Dullness to percussion Lt Rt Hyperresonance Lt Rt Tactile fremitus WNL Increased Decreased Auscultation WNL Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub Chest
Scarring consistent with
x
www.e-medtools.com x
x
x
Cardiovascular x x x
Heart sounds Clear S1 S2 No murmur, rub or gallop Gallop audible Rub audible Murmur present Systolic Diastolic Grade I II III IV V VI Peripheral pulses Palpable and symmetric Absent Weak Peripheral edema Absent Present
Gastrointestinal x
Abdomen
WNL Mass present LUQ RUQ LLQ RLQ Pulsatile
Liver and spleen Palpable and WNL Unable to palpate Liver Spleen Organomegaly Liver Spleen Lymphatics (2 areas must be examined)
www.e-medtools.com x
x
Lymph node exam WNL Areas examined Lymphadenopathy noted Neck
Musculoskeletal x x
Neck Axilla Groin Other Submental Axillary Epitrochlear Inguinal Other
Muscle tone WNL, and no atrophy noted
Gait and station WNL Ataxia
Extremities
Increased Decreased Atrophy present Wide based gait Shuffle Patient leans Rt Lt Front Back
x
Exam WNL Clubbing
Cyanosis Petechiae Synovitis Rt Lt
x
Exam
Ecchymosis
www.e-medtools.com Skin
WNL
Rash
Neurologic x
Ulcer
Orientation Oriented NOT oriented to Person Time Place
x Affect WNL Additional Findings
©MB and RR 2006-2010
Nodules
[email protected]
Agitated Anxious Depressed
Revised 3Feb2010
Health Care Provider Signature
www.e-medtools.com Outpatient Pulmonary Evaluation
Patient Name
DOB
MRN
Impression and Plan Data Reviewed
ER Notes Old medical records Labs Radiology data Pathology ECHO, EKG or Stress Test Pulmonary Function Test
I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate decision maker) understands their medical condition, their prognosis and the consequences of their Code Status decision. Code Status Patient is a FULL CODE DO NOT ATTEMPT Cardiac Resuscitation DO NOT Intubate
www.e-medtools.com
This patient has advanced health care directives. Their HCPOA is
Care Coordinated with
Patient HCPOA / Surrogate Other physician or Consultant Pharmacy Diagnostic Evaluation Plan Labs
CBC with differential PT, PTT, INR Metabolic Panel BNP Cardiac Enzymes HIV Thyroid function studies Influenza swab, wash or aspirate Quantiferon Serum Mycoplasma Urine Antigen for Histoplasma Legionella Cultures Antibodies ANA (SLE) ds-DNA (SLE) ANCA (vasculitis not PAN) RF Anti-CCP (RA) Jo (PM/DM) Topoisomerase (Scl-70) anti-RNP (Scleroderma and SLE) GM-CSF (Pulm Alveolar Proteinosis) Ro, La (Sjogren) Cryoglobulins Complements (C3, C4) EKG ECHO Cardiac Stress Test Cardiac Rehab Pulmonary Function Test Cardiopulmonary Exercise Test Sleep Study Pulmonary Rehab PPD
www.e-medtools.com
www.e-medtools.com
www.e-medtools.com
www.e-medtools.com C-FNP or PA-C Signature I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above and I agree with the assessment and plan as outlined.
Physician Signature cc
Chest X-Ray CT of Chest with contrast ©MB and RR 2006-2010
[email protected]
Revised 3Feb2010
Health Care Provider Signature
©MB and RR 2006-2010
Patient Name
DOB
Chief complaint/Reason for consult Yes
No
MRN
Start Time
Stop Time
Date
History of Present Illness
www.e-medtools.com
Allergies and Medications
Allergy List reviewed No drug allergies No food allergies Medications reviewed Medications reconciled with Nursing Home data
www.e-medtools.com
Past Medical, Family Social History (PFSH) Past Medical History
Asthma COPD Congestive Heart Failure(CHF) Coronary Artery Disease
Diabetes Hepatic Dysfunction HIV/AIDS Hypertension
Obstructive Sleep Apnea Other Seizure Disorder Thyroid disease Hyper Hypo Tuberculosis
No Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid Treatment Surgical Resection Chemotherapy Radiation Malignancy
www.e-medtools.com
ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers Vaccines This patient is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella Tetanus Surgeries
Appendectomy Arterial bypass Coronary Artery Bypass Cardiac valve repair or replace Carotid Endarterectomy
Cholecystectomy Colon resection Hysterectomy Nephrectomy Splenectomy
Pacemaker Defibrillator
Organ transplant Other
Hip replacement Knee replacement
Social History Risk factors
Denies Yes ■ Denies Yes
Tobacco use Number Pack-Years _________ Quit tobacco use Quit date _________ ■ Willingness to Quit Unwilling Considering Quit but resumed Within 1 month Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade
www.e-medtools.com
Denies Yes Denies Yes
Recreational drug use Route Inhalation Injection Ingestion Drug dependence Type Narcotics Benzodiazepines
Denies Yes
Alcohol use ___ Drinks per Day Week
Buproprion or nortriptyline
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 Hot tub or Jacuzzi High Pressure washings Pets or feathers Chemicals or fires
www.e-medtools.com
Military HIstory Family History
Asthma Coronary Artery Disease CHF Pancreatitis COPD Peripheral Artery Disease [email protected]
Renal Dysfunction Thrombotic disorder Thyroid Disease
Revised 3Feb2010
Malignancy Other
Health Care Provider Signature
www.e-medtools.com Outpatient Pulmonary Evaluation
Patient Name
DOB
MRN
Exam Labs \____/ / \
____ / ____ / ____ / \ \ \
Constitutional WNL = Within Normal Limits Height _______ in cm Weight _______
lb kg Temperature _____
Respiratory Rate _______ Pulse Rate _______ AND Rhythm Regular Irregular www.e-medtools.com Blood Pressure Sitting __________ OR Standing __________ OR Lying __________
Optional Sats _____ % x
Body habitus WNL
x
Grooming
ENT x x x
Cachectic Obese WNL Unkempt
WNL Edema or erythema present Gingivitis Oropharynx WNL Edema or erythema present Oral ulcers Oral Petechiae Mallampati I II III IV Nasal mucosa, septum, and turbinates
Dentition and gums WNL Dental caries
www.e-medtools.com Neck x
Radiology
x
CXR CT/Chest Other
WNL Erythema or scarring consistent with recent or old radiation dermatitis Nodules palpable Neck mass Jugular Veins WNL JVD present a, v or cannon a waves present Neck
Thyroid WNL Thyromegaly
x Respiratory x
Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis Old, healed radiation dermatitis Prior surgery Trauma Other Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements Chest percussion WNL Dullness to percussion Lt Rt Hyperresonance Lt Rt Tactile fremitus WNL Increased Decreased Auscultation WNL Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub Chest
Scarring consistent with
x
www.e-medtools.com x
x
x
Cardiovascular x x x
Heart sounds Clear S1 S2 No murmur, rub or gallop Gallop audible Rub audible Murmur present Systolic Diastolic Grade I II III IV V VI Peripheral pulses Palpable and symmetric Absent Weak Peripheral edema Absent Present
Gastrointestinal x
Abdomen
WNL Mass present LUQ RUQ LLQ RLQ Pulsatile
Liver and spleen Palpable and WNL Unable to palpate Liver Spleen Organomegaly Liver Spleen Lymphatics (2 areas must be examined)
www.e-medtools.com x
x
Lymph node exam WNL Areas examined Lymphadenopathy noted Neck
Musculoskeletal x x
Neck Axilla Groin Other Submental Axillary Epitrochlear Inguinal Other
Muscle tone WNL, and no atrophy noted
Gait and station WNL Ataxia
Extremities
Increased Decreased Atrophy present Wide based gait Shuffle Patient leans Rt Lt Front Back
x
Exam WNL Clubbing
Cyanosis Petechiae Synovitis Rt Lt
x
Exam
Ecchymosis
www.e-medtools.com Skin
WNL
Rash
Neurologic x
Ulcer
Orientation Oriented NOT oriented to Person Time Place
x Affect WNL Additional Findings
©MB and RR 2006-2010
Nodules
[email protected]
Agitated Anxious Depressed
Revised 3Feb2010
Health Care Provider Signature
www.e-medtools.com Outpatient Pulmonary Evaluation
Patient Name
DOB
MRN
Impression and Plan Data Reviewed
ER Notes Old medical records Labs Radiology data Pathology ECHO, EKG or Stress Test Pulmonary Function Test
I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate decision maker) understands their medical condition, their prognosis and the consequences of their Code Status decision. Code Status Patient is a FULL CODE DO NOT ATTEMPT Cardiac Resuscitation DO NOT Intubate
www.e-medtools.com
This patient has advanced health care directives. Their HCPOA is
Care Coordinated with
Patient HCPOA / Surrogate Other physician or Consultant Pharmacy Diagnostic Evaluation Plan Labs
CBC with differential PT, PTT, INR Metabolic Panel BNP Cardiac Enzymes HIV Thyroid function studies Influenza swab, wash or aspirate Quantiferon Serum Mycoplasma Urine Antigen for Histoplasma Legionella Cultures Antibodies ANA (SLE) ds-DNA (SLE) ANCA (vasculitis not PAN) RF Anti-CCP (RA) Jo (PM/DM) Topoisomerase (Scl-70) anti-RNP (Scleroderma and SLE) GM-CSF (Pulm Alveolar Proteinosis) Ro, La (Sjogren) Cryoglobulins Complements (C3, C4) EKG ECHO Cardiac Stress Test Cardiac Rehab Pulmonary Function Test Cardiopulmonary Exercise Test Sleep Study Pulmonary Rehab PPD
www.e-medtools.com
www.e-medtools.com
www.e-medtools.com
www.e-medtools.com C-FNP or PA-C Signature I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above and I agree with the assessment and plan as outlined.
Physician Signature cc
Chest X-Ray CT of Chest with contrast ©MB and RR 2006-2010
[email protected]
Revised 3Feb2010
Health Care Provider Signature
Related Documents
Pulmonary Clinic History And Physical
October 2019 14
History And Physical Exam
October 2019 13
Dizziness History And Physical Examination
April 2020 9
Clinic
May 2020 52
Pulmonary Hypertension And Cor Pumonale
June 2020 4