lung mass evaluation
DESCRIPTION
The lung mass evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with lung masses and potential lung cancer. The discovery of a lung mass provokes great fear, because this discovery may be the first sign of lung cancer or other cancer. Because of the risk of cancer, a thorough and timely evaluation of a lung mass is imperative.The Centers for Disease Control and Prevention states, ”More people die from lung cancer than any other type of cancer. This is true for both men and women. In 2003 (the most recent year for which statistics are currently available), lung cancer accounted for more deaths than breast cancer, prostate cancer, and colon cancer combined.”In 2003 nearly 200,000 people were diagnosed with lung cancer. In that same year, 160,000 died from lung cancer. The treatment for lung cancer is not very effective, unless detected and treated in the earliest, often asymptomatic, stages.Not all lung masses are due to cancer. Lung masses can develop as a result of infection, primarily tuberculous and fungal infections. Other disease processes associated with lung masses include rheumatoid arthritis, sarcoidosis, silicosis, and arteriovenous malformations.Questions relating to smoking history, drug abuse, and alcohol abuse are standard in MedicalTemplates. These questions have increased importance in the evaluation of patients with lung masses. Patients who smoke are at 10-20 times more likely to develop lung cancer, and many other cancers (i.e., gastric, pancreatic, cervical, larynx, esophagus and colon cancer) are also related to smoking.TRANSCRIPT
Lung Mass Evaluation Patient Name DOB MRN Date
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Review of Systems Yes NoConstitution�Fatigue or Malaise� � �Fever or chills� � �Appetite changes� � �Eyes�Conjunctivitis� � �New eye painBlurred visionENT/mouthSore throatSwollen uvulaJaw pain RespiratoryDyspneaCoughPhlegmHemoptysisWheezePleuritic SymptomsCardiovascularChest painDiaphoresisAnkle edemaSyncopePalpitationsGastrointestinalNausea or vomitingWeight changesDiarrheaAbdominal painGenitourinaryHematuriaDysuriaUrethral dischargeMusculoskeletalMyalgiasArthralgiasJoint swellingRecent traumaSkin/BreastsMassesNew skin lesionsRashNeurologicHeadachesSeizuresNumbnessParesthesiasEndocrinologicHair lossPolydipsiaTremorsNeck painHeme/LymphBleeding gumsUnusual bruisingSwollen lymph nodesAllergy/ImmunologyNasal congestionRhinorrheaPsychologicAgitationHallucinations
History of Present Illness �Patient is Nonverbal. History obtained from �Family �Medical records
����������History of recent travel�History of chemotherapy, use of immunosuppressive drugs, or immunosuppressive disease
Allergies and Medications
�Allergy List reviewed �No drug allergies �No food allergies��Medications reviewed �Medications reconciled with Nursing Home data
Past Medical, Family Social History (PFSH)Past Medical History�Asthma �Diabetes �Obstructive Sleep Apnea �Other�COPD �Hepatic Dysfunction �Seizure Disorder��
�Congestive Heart Failure(CHF) �HIV/AIDS �Thyroid disease �Hyper �Hypo
�Coronary Artery Disease�� �Hypertension �Tuberculosis
Malignancy �Yes �No �Adrenal �Breast �Colon �Leuk/Lymph �Lung �Melanoma �Renal cell �Skin �Pituitary �Prostate �Testicular �Thyroid Treatment �Surgical Resection �Radioablation �Chemotherapy �Radiation
ADLs This patient is able to perform the following independently �Eating �Bathing �Dressing �Toileting �TransfersVaccines This patient is current on the following �Seasonal Influenza �Pneumococcal �Varicella �Pertussis �Tetanus
Surgeries �Appendectomy �Cholecystectomy �Pacemaker �Organ transplant �Arterial bypass �Colon resection �Defibrillator ��Coronary Artery Bypass �Hysterectomy �Other �Cardiac valve repair or replace �Nephrectomy �Hip replacement �Carotid Endarterectomy �Splenectomy �Knee replacement
Social History Risk factors �No �Yes Tobacco use Number Pack-Years _________ �No �Yes 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 �Buproprion or nortriptyline
�No �Yes Recreational drug use Route �Inhalation �Injection �Ingestion �No �Yes Drug dependence Type �Narcotics �Benzodiazepines
�No �Yes Alcohol use ___ Drinks per �Day �Week
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��Aerosolized water Source �Hot tub �Whirlpool baths �High Pressure washings �Other�Pets or feathers �Chemicals or fires �Military Experience
Family History�Asthma �Coronary Artery Disease �Renal Dysfunction �Malignancy�CHF �Pancreatitis �Thrombotic disorder �Other�COPD �Peripheral Artery Disease �Thyroid Disease
Sample
Lung Mass Evaluation Patient Name DOB MRN Date
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Exam WNL = Within Normal Limits
VitalsHeight _______ �in �cm
Weight _______ �lb �kg
Temperature _______ �C �F Pulse Rate _______Rhythm �Regular �Irregular
Blood Pressure ____________�Sitting �Standing �Lying Oxygen Saturation (Pulse oximetry)
_______ �Rest �Exercise
_______ �Rest �Exercise
NonInvasive Ventilator �CPAP �BiPAP Ins ____ Exp ____ Ventilator Mode �AC�SIMV�PC�PRVC
Date of Intubation ________________
�Endotracheal Tube Size _____�Tracheostomy Tube Size _____
Rate ____ Tidal Vol ____ FiO2 ____
PEEP level ______ Pressure Support level ______
Peak Inspiratory Pressure ______Plateau Pressure ______
ARDS ALI PO2/FiO2 �<200 �201-300 �>300
Labs
\____/ ____ / ____ / ____ // \ \ \ \
Radiology�CXR �CT/Chest �Other
Constitutional Body habitus �WNL �Cachectic �Obese
Grooming �WNL �Unkempt �ENT
Nasal mucosa, septum, and turbinates �WNL �Edema or erythema present
Dentition and gums �WNL �Dental caries �Gingivitis
Oropharynx �WNL �Edema or erythema present �Oral ulcers �Oral Petechiae
Mallampati �I �II �III �IVNeck
Neck �WNL �Erythema or scarring consistent with �recent or �old radiation dermatitis
Thyroid �WNL �Thyromegaly �Nodules palpable �Neck mass
Jugular Veins �WNL �JVD present �a, v or cannon a waves present Respiratory
Chest �Free of defects, expands normally and symmetrically �Erythema consistent with radiation dermatitis
Scarring consistent with �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 present Cardiovascular
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 Abdomen �WNL �Mass present �LUQ �RUQ �LLQ �RLQ �Pulsatile
Liver and spleen �Palpable and WNL Unable to palpate �Liver �Spleen Organomegaly�Liver �SpleenLymphatics (�2 areas must be examined)
Lymph node exam �WNL Areas examined �Neck �Axilla �Groin �Other
Lymphadenopathy noted �Neck �Submental �Axillary�Epitrochlear �Inguinal �Other Musculoskeletal
Muscle tone �WNL, and no atrophy noted �Increased �Decreased �Atrophy present
Gait and station �WNL �Ataxia �Wide based gait �Shuffle Patient leans �Rt �Lt �Front �BackExtremities
Exam �WNL �Clubbing �Cyanosis �Petechiae �Synovitis �Rt �Lt Skin
Exam �WNL �Rash �Ecchymosis �Nodules �UlcerNeurologic
Orientation �Oriented �NOT oriented to �Person �Time �Place
Cranial Nerves �Intact
Deficit noted CN �II �III � IV �V �VI �VII �VIII �IX �X� XI �XII
Deep Tendon Reflexes �Appropriate and symmetric �Babinski present �Other
Sensation �Intact Deficit noted in �Touch �Pin �Vibration �Proprioception
Additional Findings
Sample
Lung Mass Evaluation Patient Name DOB MRN Date
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Impression and Plan
Data Reviewed���ER Notes �Old medical records �Labs �Previous radiographic imaging data �Pathology�ECHO �ECG�Stress Test �Pulmonary Function Test
Care Coordinated with �Patient �HCPOA / Surrogate �Other physician or Consultant�Case Management or Social Worker �Pharmacy �Nursing
Recommended Diagnostics�CBC with differential�PT, PTT, INR�Metabolic Panel �HIV ��PPD �Quantiferon �Sputum Cytology�Urine for Histoplasma and Legionella
Cultures�Sputum �Bacterial �Fungal �AFB
�Blood �Urine �CSF �Computed Tomography (CT)�Chest �Abdomen/Pelvis �Head �Neck
��Positron Emission Tomography (PET) ��ECG�ECHO
�Bronchoscopy�Transthoracic Needle Biopsy�Cardiothoracic Surgery Consult
�Other
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
� This patient has advanced health care directives. Their HCPOA is
Signature ��Physician �Resident �C-FNP �PA-C
�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.
Supervising Physician Signaturecc
Sample