Outpatient Pulmonary Evaluation Patient Name DOB MRN

©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature

Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date

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

������

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 �No �Adrenal �Breast �Colon �Leuk/Lymph �Lung �Melanoma �Renal cell �Skin �Pituitary �Prostate �Testicular �Thyroid Treatment �Surgical Resection �Chemotherapy �Radiation

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 �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 �Denies �Yes Tobacco use Number Pack-Years _________ �Denies �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

�Denies �Yes Recreational drug use Route �Inhalation �Injection �Ingestion �Denies �Yes Drug dependence Type �Narcotics �Benzodiazepines

�Denies �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��Hot tub or Jacuzzi�High Pressure washings�Pets or feathers�Chemicals or fires��

Military HIstory

Family History�Asthma �Coronary Artery Disease �Renal Dysfunction �Malignancy�CHF �Pancreatitis �Thrombotic disorder �Other

�COPD �Peripheral Artery Disease �Thyroid Disease

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

■

■

Outpatient Pulmonary Evaluation Patient Name DOB MRN

©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature

Exam

Labs

\____/ ____ / ____ / ____ // \ \ \ \

Radiology�CXR �CT/Chest �Other

Constitutional WNL = Within Normal Limits

Height _______ �in �cm Weight _______ �lb �kg � Temperature _____ ���

Respiratory Rate _______ Pulse Rate _______ AND Rhythm �Regular �Irregular

Blood Pressure Sitting __________ OR Standing __________ OR Lying __________

Optional Sats _____ %

� 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 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

� Affect �WNL �Agitated �Anxious �DepressedAdditional Findings

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

Outpatient Pulmonary Evaluation Patient Name DOB MRN

©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature

Impression and Plan

Data Reviewed���ER Notes �Old medical records �Labs �Radiology data �Pathology�ECHO, EKG or Stress Test �Pulmonary Function Test

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

Diagnostic Evaluation PlanLabs�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

�Chest X-Ray�CT of Chest with contrast

�� 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

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 Signaturecc

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com

www.e-medtools.com