Pulmonary / Critical Care New Patient Evaluation

Pulmonary Evaluation Date

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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________

Time Yes

Constitution Fatigue Malaise Fever or chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Hallucinations

Chief complaint/Reason for consult

Referring MD

No Reset

History of Present Illness

Patient is Nonverbal. History obtained from

Family

Medical records

Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms

Reset

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Reset

Medications

Allergies

Medications reviewed

Allergy List reviewed

46

Medications reconciled with Nursing Home or Hospital discharge Information

No food or drug allergies

Past Medical, Family Social History Reset

Reset

Reset

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 Wegener’s Malignancy Obstructive Sleep Apnea CPAP BiPAP Malignancy Adrenal Colon Melanoma Renal cell

Neuromuscular weakness Occupational exposures Osteoporosis Pancreatitis Peripheral Artery Disease Scleroderma Seizure Disorder Sjogren’s Renal dysfunction/ failure Rheumatoid Arthritis Thrombotic Disease Thyroid disease

www.e-medtools.com Thyroid

Breast

Chemotherapy Colonoscopy ECHO/Stress Test Mammogram PFTs PapSmear Prior Intubations Radiation exposure Sleep Study Steroid use

Lung

Prostate

Testicular

Surgeries Reset

Social History / Risk factors

Reset

Reset

Denies Denies Denies

Yes Ever smoker ___ # Packs X ____ # Yrs Yes Chews tobacco Yes Quit tobacco use Quit date _________ Patient is unwilling to quit Patient willing to consider quitting Patient quit, but resumed smoking Patient willing to quit within 1 month

Denies

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Yes Yes Yes Yes

Denies

Yes Drug dependence Narcotics Benzodiazepines

Reset

Feels safe at home or work Tattoos High risk sexual behavior Recreational drug use Inhalational

Injectable

Ingestible

Denies Denies Denies Denies Denies

Yes Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade

Yes Yes Yes Yes Yes

Alcohol use ___ Drinks per day week Felt the need to cut down on drinking? Annoyed by others criticizing drinking? Guilt associated with drinking? Eye opener needed?

Occupational and Exposure History Reset

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 or High Pressure washings Pets or feathers Chemicals or fires

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Family Medical History Reset

Asthma CHF COPD Coronary Artery Dis Thrombotic disorder Thyroid Disease Malignancy in first degree relatives, specify

Pancreatitis

Peripheral Artery Disease

Renal Dysfunction

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services

Pulmonary Evaluation Exam

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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ General Multisystem requires performing ALL of ≥9 organ systems, AND ≥2 elements documented in each organ system

To qualify as a comprehensive exam:

Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND

Ventilator, IV Medications & Labs

Constitutional (≥ 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam

AC

PRVC Rate

in

Height ___________

Ventilator Mode

SIMV

PS

__________

FiO2

__________

Pulse Rate __________

lb

kg

AND Rhythm

Regular

Irregular

Blood Pressure sitting __________ / __________ OR standing __________ / __________ Blood Pressure lying

Tidal Vol __________ __________

Weight ___________

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__________

PEEP

cm

Temperature __________

PC

Other ____________

≥1 element in every other organ system is expected

__________ / __________

Respiratory Rate__________ Body habitus wnl

Optional Sats _____ % Cardiac Output _____ SVR _____

Cachectic

Grooming wnl

Obese

Unkempt

ENT Nasal mucosa, septum, and turbinates wnl

PO2/FiO2__________

Dentition and gums wnl

Plateau __________

Mallampati

BiPAP

I

Neck wnl

II

III

Oral ulcers

Oral Petechiae

IV

Erythema or scarring consistent with

Thyroid wnl

IV Medications Pressors

Gingivitis

Oropharyngeal edema or erythema

Neck

NonInvasive Ventilator CPAP

Dental caries

www.e-medtools.com Oropharynx wnl

Dose

____________________________

Thyromegaly

Jugular Veins wnl

Rate

Respiratory effort is wnl

Chest percussion wnl Tactile exam wnl

Antiarrhythmics

____________________________

Clear S1 S2

Paralytic

Hyperresonance

Lt

Rt

Egophony (E to A)

Rales

Rhonchi

Wheezes

Gallop

Diastolic Grade

Rub I

II

No peripheral edema

III

IV

V

Peripheral pulses

VI

Absent

Weak

GI Abdominal exam wnl Mass present

LUQ

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RUQ

Liver and spleen palpation wnl Unable to palpate Lymph (≥2 areas must be examined) Lymph node exam wnl Areas examined Lymphadenopathy noted in

Neck

Neck Axilla

LLQ

Liver

RLQ ____________________

Spleen Enlarged

Axilla

Groin

Groin

Liver

Pulsatile

Spleen

Other ___________________

Other ___________________

Musc Muscle tone within normal limits, and no atrophy noted Tone is

Thrombolytic

____________________________

Increased

Decreased

Atrophy present

Gait and station wnl

TPN

Ataxia

Wide based gait

Shuffle Patient leaning

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Rt

Lt

Front

Back

Extrem

Exam wnl

\____/ / \

Systolic

Peripheral pulses palpable

____________________________

Labs

Rt

Decreased _____________________________________

Bronchial breath sounds

No murmur, rub or gallop

Murmur present

Steroids

____________________________

Lt

Increased

CV

Heparin Insulin

Intercostal retractions

Rub present ________________________

Narcotics

____________________________

Dullness to percussion

Tactile fremitus

Clear to auscultation

____________________________ ____________________________

Accessory respiratory muscle use

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____________________________ Sedation

Erythema consistent with radiation dermatitis

Paradoxic diaphragmatic movements

____________________________

____________________________

Neck mass ___________________________

a, v or cannon a waves present

Scarring consistent with old, healed radiation dermatitis

____________________________

Antibiotics

Thyroid nodules palpable

JVD present

Chest is free of defects, expands normally and symmetrically

Antihypertensives

____________________________

Old radiation dermatitis

Resp

____________________________

Diuretics

Recent

Clubbing

Cyanosis

Petechiae

Synovitis

Rt

Lt ________________________

Skin No rashes, ecchymoses, nodules, ulcers

Periungual telangiectasias

Splinter hemorrhages

Neuro ____ / ____ / ____ / \ \ \

Oriented

58(Pts with Community Acquired Bacterial Pneumonia)

Affect is within normal limits OR Patient appears Glasgow Coma Score E _____ V _____ M _____

NOT oriented to

Agitated

Anxious

Person

Time

Place

Depressed

APACHE II Score __________

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services

Pulmonary Evaluation

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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________

Data Reviewed

Impression Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION Patient has completed advanced health care directives 47 HCPOA is _______________________________________

ER Notes Old medical records Labs Radiology data ECHO ECG

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Stress Test Pulmonary Function Test Nursing Notes/Vitals log

Care Coordinated with Patient HCPOA / Surrogate PCP Consultant Case Management or Social Worker Pharmacy Nursing

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Physical Therapist Occupational Therapist Speech Therapist

Recommended Actions Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Daily sedation vacation and neurologic assessment Head of bed elevated > 30 Degrees at all times Intense glycemic control Insulin infusion

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Central line change or removal (send tip for culture) Physical therapy Enteral/Parenteral feeds Smoking cessation aids Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge

Recommended Diagnostics

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PPD Testing 12-lead EKG Echocardiogram Sputum culture Bacterial

Fungal

AFB

Blood culture Urine culture CSF culture

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CBC with differential PT, PTT, INR BMP (with calcium) HIV Hepatitis panel

Signature ________________________________________

cc __________________________________

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services

www.e-medtools.com Date Start time

Pulmonary and Critical Care New Patient Evaluation Template Definitions Sepsis

Stop time

APACHE II Score - To be obtained within first 24 hours of ICU Admission APACHE II: a severity of disease classification system Crit Care Med 1985 13(10):818-29 An evaluation of outcome from intensive care in major medical centers Ann Intern Med 1986 104(3):410 Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II and III prognostic systems in a United Kingdom intensive care unit Crit Care Med 1997 25(1):9-15 Physiologic Variable 0 1 2 3 4 Temperature 96.8-101.2 101.3-102.1 89.6-93.1 102.2-105.7 >105.7 93.2-96.7 Heart Rate 70-109 n/a 110-139 140-179 >161 55-69 40-54 < 50

Positive blood culture AND Heart rate >⁄= 90 Temp <⁄= 36 C or >⁄= 38 C Resp rate >⁄= 20 OR PCO2 <⁄= 32 on ABG WBC <⁄=4000 OR >⁄= 12000 OR >⁄= 10% Bands Without a positive blood culture, the above findings are consistent with Systemic Inflammatory Response Syndrome (SIRS)

Severe Sepsis The patient must meet the above criteria AND have hypotension, hypoperfusion or organ dysfunction. Hypotension is defined as SBP < 90 MAP <⁄= 70 mmHg OR drop of >/= 40 mmHg

Septic Shock The patient must meet the above criteria AND have refractory shock (hypotension not responsive to fluid resuscitation). Systolic BP <⁄= 90,or MAP <⁄= 70

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MAP (2 x DBP + SBP)/3 Resp Rate

70-109

n/a

12-24

25-34 10-11

Oxygenation If FiO2 > 49%, A-a

< 200

If FiO2 < 50%, PO2

110-129 50-69 6-9

130-159 35-49

200-349

350-499

Acute Respiratory Distress Syndrome (ARDS) PO2/FiO2 <⁄=200

______

>500

Serum Creatinine ______ Art pH

______

WBC

______

Hct

______

GCS

______

61-70

55-60

<54

155-159 120-129

160-179 111-119

>179 < 111

Serum K+

3.5-5.4

5.5-5.9 3.0-3.4

2.5-2.9

6.0-6.9

>7.1 < 2.5

Serum Creatinine (Double if in ARF) Arterial pH

0.6-1.4

n/a

2.0-3.4

>3.4

7.33-7.49

7.50-7.59

1.5-1.9 <0.6 7.25-7.32

WBC

3.0-14.9

15-19.9

Hematocrit

30-45.9

46-49.9

7.60-7.69 7.15-7.24

>7.69 <7.15

20-39.9 1.0-2.9

n/a

>39 <1.0

50-59.9 20-29.9

n/a

>59 <20

GCS Score = 15 – GCS Score (Eye + Motor + Verbal)

Total APACHE II Score = Acute Physiology Score + Chronic Health Points + Age Points

Age Score ______

PO2 56-59 OR Sats 89% WITH CHF Cor pulmonale P wave >2mm lead II, III or AVF Hct >56% Sats <⁄=88% for >5 minutes during sleep NOT COVERED PO2 >59 OR Sats >89%

©MB and RR 2006, 2007

4 5

15-29 <15

Glasgow Coma Score Eye response _____ 1 -None 2 - Eyes open to pain 3 - Opens to verbal command 4 - Open spontaneously Verbal response _____ 1 – None 2 – Incomprehensible sounds 3 – Inappropriate words 4 – Confused 5 – Oriented

3 – Flexion to pain 4 – Withdrawal from pain 5 – Localizes pain 6 – Obeys commands Total Score < 9 indicates severe brain injury LANCET (ii) 81-83, 1974.

Predicted Mortality Based on APACHE II Score Score

Total APACHE II Score ______ 0-4

1. Head of bed elevated by >/= 30 degrees Stages of chronic kidney disease 2. Daily sedation vacation AND Stage GFR (mL/min/1.73m2 ) Action assessment of ability to wean from 1 >89 Diagnosis and treatment. Treat comorbid conditions. Slow progression. ventilator 2 60-89 Estimate progression 3. Stress ulcer prophylaxis 3 38-59 Evaluate and treat complications 4. Deep Venous Thrombosis prophylaxis

Oxygen Coverage PO2<⁄=55 OR Sats <⁄=90%

Physiology Score ______

CHP Score ______ 2 – Extension to pain

Age Points for APACHE II <45 = 0 45-54 = 2 55-64 = 3 65-74 = 5 >74 = 6

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15 – GCS Score (Eye + Motor + Verbal)

Motor Response _____ 1 – None

5 2

Cirrhosis with portal hypertension OR encephalopathy; class IV angina; chronic hypoxia; hypercarbia or polycythemia; chronic dialysis; immunocompromised

Ventilator Strategies (www.ihi.org)

______

Serum K

150-154

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RR

______

>70

Chronic Health Points for APACHE II Non-operative, or emergency post-op & any conditions below Elective operation & any conditions below

______

Serum Na

Physiology Score ______ Institute for Healthcare Improvement (www.ihi.org) 1. Blood cultures before administration of broad spectrum antibiotics 2. Broad spectrum antibiotics given in /= 70% OR SvO2 >/= 65% in
MAP

______

130-139

Sepsis Treatment Goals

______

Oxygenation

Acute Lung Injury Bilateral infiltrates on radiograph PO2/FiO2 201-300 regardless of PEEP No evidence of elevated left atrial pressure OR PCWP < 18 mmHg

HR

>181 <40 >49 <6

Serum Na+

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Physiologic Score Temp ______

5-9 10-14 15-19 20-24 25-29 30-34 over 34

Interpretation ~4% death rate ~8% death rate ~15% death rate ~25% death rate ~40% death rate ~55% death rate ~75% death rate ~85% death rate

Prepare for kidney replacement therapy Replacement (if uremia is present)

The National Kidney Foundation recommends estimating GFR by use of the Cockcroft-Gault or MDRD equations

General Acid-Base Rules Acidosis Acute Resp ∆pH = -0.008 x ∆PCO2 ∆HCO3 = 0.1 x ∆PCO2 (+/-3)

Alkalosis ∆pH = 0.008 x ∆PCO2 ∆HCO3 = -0.2 x ∆PCO2 (usually not to less than 18 mEq/L) ∆HCO3 = -0.4 x ∆PCO2 (usually not to less than 18 mEq/L) PCO2 = 0.9(HCO3) + 9 +/-2 ∆PCO2 = 0.6 x ∆HCO3

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Chronic Resp PCO2 = 2.4(HCO3) – 22 ∆HCO3 = 0.35 x ∆PCO2 (+/-4) Metabolic PCO2 = 1.5(HCO3) + 8 +/-2 PCO2 ~ last 2 digits pH ∆PCO2 = 1.2 x ∆HCO3

Revised 13Nov07

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Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures