Pulmonary Clinic History and Physical

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Outpatient Pulmonary Evaluation Patient Name DOB MRN
Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date
Review of Systems Yes No
Constitution
Fatigue or Malaise History of Present Illness
Fever or chills

Appetite changes
Eyes www.e-medtools.com
Conjunctivitis
New eye pain

Blurred vision
ENT/mouth
Sore throat
Swollen uvula
Jaw pain
Allergies and Medications
Respiratory
Dyspnea Allergy List reviewed No drug allergies No food allergies
Cough
Phlegm Medications reviewed Medications reconciled with Nursing Home data
Hemoptysis
Wheeze
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Past Medical, Family Social History (PFSH)
Pleuritic Symptoms Past Medical History
Cardiovascular Asthma Diabetes Obstructive Sleep Apnea Other
Chest pain
COPD Hepatic Dysfunction Seizure Disorder
Diaphoresis
Congestive Heart Failure(CHF) HIV/AIDS Thyroid disease Hyper Hypo
Ankle edema
Coronary Artery Disease Hypertension Tuberculosis
Syncope
Palpitations Malignancy No
Gastrointestinal
Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid
Nausea or vomiting
Treatment Surgical Resection Chemotherapy Radiation
Weight changes
Diarrhea
Abdominal pain
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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
Genitourinary
Hematuria Surgeries
Dysuria Appendectomy Cholecystectomy Pacemaker Organ transplant
Urethral discharge Arterial bypass Colon resection Defibrillator
Musculoskeletal Coronary Artery Bypass Hysterectomy Other
Myalgias Cardiac valve repair or replace Nephrectomy Hip replacement
Arthralgias Carotid Endarterectomy Splenectomy Knee replacement
Joint swelling
Social History Risk factors
Recent trauma
Denies Yes Tobacco use Number Pack-Years _________
Skin/Breasts
■ Denies Yes
Masses
New skin lesions
www.e-medtools.comQuit 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 Buproprion or nortriptyline
Rash
Neurologic Denies Yes Recreational drug use Route Inhalation Injection Ingestion
Headaches Denies Yes Drug dependence Type Narcotics Benzodiazepines
Seizures
Numbness
Denies Yes Alcohol use ___ Drinks per Day Week
Paresthesias Occupational and Exposure History

Endocrinologic Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Hair loss Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Polydipsia
Tremors www.e-medtools.com
Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Hot tub or Jacuzzi
Neck pain
High Pressure washings
Heme/Lymph
Bleeding gums
Pets or feathers
Unusual bruising
Chemicals or fires
Swollen lymph nodes
Military HIstory
Allergy/Immunology
Nasal congestion
Family History
Rhinorrhea
Psychologic Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Agitation CHF Pancreatitis Thrombotic disorder Other
Hallucinations COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature
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Exam
Labs Constitutional WNL = Within Normal Limits
Height _______ in cm Weight _______ lb kg Temperature _____
\____/ ____ / ____ / ____ /
/ \ \ \ \

Respiratory Rate _______ Pulse Rate _______ AND Rhythm Regular Irregular
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Blood Pressure Sitting __________ OR Standing __________ OR Lying __________
Optional Sats _____ %
x Body habitus WNLCachectic Obese

x Grooming WNL Unkempt
ENT
x WNL Edema or erythema present
Nasal mucosa, septum, and turbinates
x Dentition and gums WNL Dental caries
Gingivitis
x Oropharynx WNL Edema or erythema present Oral ulcers Oral Petechiae
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Mallampati I II III IV
Neck
x Neck WNL Erythema or scarring consistent with recent or old radiation dermatitis
x Thyroid WNL Thyromegaly Nodules palpable Neck mass
Radiology
x Jugular Veins WNL JVD present a, v or cannon a waves present
CXR CT/Chest Other
Respiratory
x Chest Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Scarring consistent withOld, healed radiation dermatitis Prior surgery Trauma Other
x Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements
Chest percussion WNL Dullness to percussion Lt Rt Hyperresonance Lt Rt
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x
x Tactile fremitus WNL Increased Decreased
x Auscultation WNL Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub
Cardiovascular
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
x Peripheral pulses Palpable and symmetric Absent Weak
x 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
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x
Lymphatics (2 areas must be examined)
x Lymph node exam WNL Areas examined Neck Axilla Groin Other
Lymphadenopathy noted Neck Submental Axillary Epitrochlear Inguinal Other
Musculoskeletal
x Muscle tone WNL, and no atrophy noted Increased Decreased Atrophy present
x Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extremities
x Exam WNL Clubbing Cyanosis Petechiae Synovitis Rt Lt
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Skin

x Exam WNL Rash Ecchymosis Nodules Ulcer
Neurologic
x Orientation Oriented NOT oriented to Person Time Place
x Affect WNL Agitated Anxious Depressed
Additional Findings
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Impression and Plan
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
Radiology data www.e-medtools.com
DO NOT ATTEMPT Cardiac Resuscitation
DO NOT Intubate
Pathology
ECHO, EKG or Stress Test
This patient has advanced health care directives. Their HCPOA is
Pulmonary Function Test
Care Coordinated with
Patient
HCPOA / Surrogate
Other physician or Consultant
Pharmacy
Diagnostic Evaluation Plan
Labs
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CBC with differential
PT, PTT, INR
Metabolic Panel
BNP
Cardiac Enzymes
HIV
Thyroid function studies
Influenza swab, wash or aspirate
Quantiferon
Serum Mycoplasma www.e-medtools.com
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) www.e-medtools.com
anti-RNP (Scleroderma and SLE)
GM-CSF (Pulm Alveolar Proteinosis)
Ro, La (Sjogren)
Cryoglobulins
Complements (C3, C4)

EKG
ECHO
Cardiac Stress Test www.e-medtools.com
Cardiac Rehab
Pulmonary Function Test C-FNP or PA-C Signature
Cardiopulmonary Exercise Test I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient
Sleep Study with the NP or PA above and I agree with the assessment and plan as outlined.
Pulmonary Rehab
PPD Physician Signature
cc
Chest X-Ray
CT of Chest with contrast

Pulmonary Clinic History and Physical

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Paresthesias Occupational and Exposure History

Optional Sats _____ %

x Body habitus WNLCachectic Obese

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Pulmonary Clinic History and Physical

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Paresthesias Occupational and Exposure History

Optional Sats _____ %

x Body habitus WNLCachectic Obese

Anda mungkin juga menyukai

x Body habitus WNLCachectic Obese