pneumonia evaluation

Pneumonia 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 �CABG �Cardiac valve replacement �Splenectomy �Organ transplant � Joint replacement �Other

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

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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

�Oriented NOT oriented to �Person �Time �Place

�Affect is within normal limits OR Patient appears �Agitated �Anxious �Depressed

Additional FindingsSample



Medical Decision Making Impression and Plan

Data Reviewed��ER Notes �Old medical records �Previous radiographic imaging data �ECHO �Pulmonary Function Test

Care Coordinated with �Patient �HCPOA / Surrogate �Other physician or Consultant

Recommended Diagnostics�CBC with differential�PT, PTT, INR�Metabolic Panel �Basic �Complete�HIV �Quantiferon ��Urine for Histoplasma and Legionella�Serum mycoplasma��Culture, Sputum � Culture, Blood ��Chest CT (Computed Tomography)�ECHO�Bronchoscopy

Pneumonia Severity IndexAgeMale Age (in years)Female Age (in years) - 10 NH resident Age (in years) +10

Comorbid illnessesNeoplastic disease Liver disease CHF Cerebrovascular diseaseRenal disease

Physical exam findingsAltered mental status Respiratory rate >/= 30 Systolic BP < 90 Temp < 35 degrees or > 40 Pulse > 124

Lab FindingspH <7.35 BUN >10.7 mmol/L Sodium <130 mEq/L Glucose > 13.9 mmol/L Hematocrit <30 percent pO2 <60 mmHg Pleural effusion

Risk Class Total�Low I Algorithm�Low II < 71 points�Low III 71-90 points�Moderate IV 91-130 points�High V >130 points

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 Resident, NP or PA above and I agree with the assessment and plan as outlined.

Supervising Physician Signaturecc

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pneumonia evaluation

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