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COPDEvaluation
Patient DOB MRN
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature
Date TimeChief complaint/Reason for consult Referring MD
YesNo
Constitution
Fatigue or Malaise
Fever or chills
Appetite changes
Eyes
Vision changes
New eye pain
ENT/mouth
Nose bleedDental cariesDental abscessesJaw pain
Respiratory
DyspneaCoughPhlegmHemoptysis
Wheeze
Cardiovascular
Chest painDiaphoresis Ankle edemaSyncopePalpitations
Gastrointestinal
Nausea or vomitingWeight changesConstipation or Diarrhea Abdominal pain
Genitourinary
HematuriaDysuriaUrethral discharge
Musculoskeletal
Myalgias ArthralgiasJoint swellingClaudication symptoms
Skin/Breasts
MassesNew skin lesionsSensitivity to sun
Neurologic
HeadachesSeizuresMuscle weakness
Endocrinologic
Hair lossPolydipsiaTremorsNeck pain
Heme/Lymph
Bleeding gumsUnusual bruisingSwollen lymph nodes
Allergy/Immunology
Sinus problemsRecurrent infections
History of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Recent Antibiotic use
Recent ER visits
Recent Weight loss or decreased appetite
Recent Oral steroid use
Recent Hospital admissions
Planned air travel in near future
Spirometry evaluation performed within previous 12 months
COPD Symptoms FEV1/FVC FEV1 SEVERITY Chronic Bronchitis symptoms
Asymptomatic with usual activity
70% >80%
At risk
Increased cough
Symptomatic with usual activity
<70% >79%
Mild
Increased dyspnea
Symptomatic with minimal activity
< 70% 50-79%
Moderate
Increased sputum production
Symptomatic at rest
<70% 30-49%
Severe
<70% <30%
Very Severe
Medications Allergies
Medications reviewed
Allergy List reviewed
Medications reconciled with Nursing Home or Hospital discharge Information
46
No food or drug allergies
Past Medical, Family SocialHistory
Asthma
Inflammatory Bowel Disease
Chemotherapy
Notes
Adrenal dysfunction
Neuromuscular weakness
Colonoscopy
Arthritis
RA
Osteoporosis
ECHO/Stress test
Blood clots
DVT
PE
Organ transplant
Immunosuppressive therapy
CHF
Pancreatitis
Mammogram
COPD
Peripheral Artery Disease
Organ failure
Coronary Artery Disease
Pituitary infarct or hemorrhage
PFTs
Cystic Fibrosis
Protein deficiency
C
S
Pap Smear
Diabetes
1
2
Renal dysfunction
ESRD
Prior intubations
Endocarditis
Hemodialysis
Peritoneal dialysis
Radiation exposure
GERD
Sarcoidosis
Sleep study
Gout
Seizure disorder
Steroid use, chronic
Hemolytic anemia
Sleep Apnea
CPAP
BiPAP
Hepatic dysfunction
Systemic Lupus Erythematosis
Tuberculosis
HIV/AIDS
Thrombocytopenia
ITP
TTP
PPD
Result
Positive
Negative
Date
Hypertension
Thyroid disease
hypo
hyper
Tuberculosis
Treatment
Malignancy
Adrenal
Colon
Leukemia/Lymphoma
Melanoma
Renal cell
Thyroid
Breast
Lung
Pituitary
Prostate
Testicular
Stage Treatment
Surgical Resection
Radioablation
Chemotherapy Last Tx
Radiation Last Tx
Surgeries
CABG
Splenectomy
Organ transplant
Lung resection
Pleurodesis
Other
Social History / Risk factors
Denies
Yes
Ever smoker
___ # Packs X ____ # Yrs
Recreational drug use
Denies
Yes
Inhalation
Injection
Ingestion
Denies
Yes
Chews tobacco
Drug dependence
Denies
Yes
Narcotics
Benzodiazepines
Denies
Yes
Quit tobacco use
Quit date _________
Alcohol use
Denies
Yes
___
Drinks per
Day
Week
Willingness to Quit
Unwilling
Considering
Quit but resumed
Within 1 month
Patient has tried smoking cessation aids
Nicotine replacement
Buproprion or nortriptyline
Nicotine receptor blockade
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
Military Experience
Chemicals or fires
Family Medical History
Asthma
CHF
COPD
Coronary Artery Disease
Malignancy
Pancreatitis
Thrombotic disorder Asthma Adrenal dysf
unctiondy
un
Arthritis A
Blood clots DVCHF
C COPDCoronar
nar Cysti
CystD
Recent Weight l
nt t ladmissions
dmilanned air tr
air tr
in previous 12 monthsou
FEV1/FVC FEV1 S
FV E S
70%
%80%
%ity<70%0%
>79%l activityac
ti< 70%
<5<70%
<7
<70%
0%iewd
cile Nuin
e ily
atory Bowel Disease
Disromuscular weakness
ular weasssteoporosis
os Organ transplantn
s ancreatitisanc
iseripheral Artery Dihe
r Diituitary infarct or i
ncrotein deficir
ot i
enal dys
al
emoo
Sar
Sar icnemiaatic dysfunctionunct
ion IV/AIDSypertension
rteion
Malignancy
Adrenal
nal
Colon
Stage Trea
De
.
petite
hronic Bronchitis sh
r tis
Increased coug
I coIncreased dy
Inc dIncreaserease
Severe
rg
lle
on
COPDEvaluation
Patient DOB MRN
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature
Exam
To qualify as a comprehensive exam:
General Multisystem requires performing ALL of
9 organ systems, AND
2 elements documented in each organ systemRespiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND
1 element in every other organ system is expected
Ventilator Mode
AC
SIMV
PC
PRVC
Intubationdate____ / ____/ ____ ETTsize _____PS
______
Rate
______
Tidal Vol
______
PEEP
______
Plateau
______
FiO2
______
PO2/FiO2
______
NonInvasive Ventilator
CPAP
BiPAP
IE
____
EE
____
IV Medications
Antiarrhythmics
Narcotics
Antihypertensives
Pressors
Diuretics
Sedation
Drotrecogin alfa
Steroids
Heparin
Thrombolytic
Insulin
TPN
Antibiotics
Lines & Monitors
Telemetry
Chest tube
Left
Air leak
present
absent
Right
Air leak
present
absent
Trach present
Size
Endotracheal tube
Size
NG/ND tube
PEG/PEJ tube
Foley catheter
Ostomy
Central line/PICC
Site
No sign of infection
Peripheral venous access
Site
No sign of infection
Port access
No sign of infecti
on
Labs
\____/ ____ / ____ / ____ // \ \ \ \
Radiology
CXR
CT/Chest
Other
Constitutional
(
3 vitals)
Body habitus
and
Grooming
required of General Multisystem but not Organ System Exam
Height
___________
in
cm
Weight
___________
lb
kg
Temperature
__________
Pulse
Rate
__________ AND
Rhythm
Regular
Irregular
Blood Pressure sitting
_____ / _____
OR
standing
_____ / _____
OR
lying
_____ / _____
Respiratory Rate
__________
Optional
Sats
_____
%Cardiac Output
_____
SVR
_____
Body habitus wnl
Cachectic
Obese
Grooming wnl
Unkempt
ENT
WNL = Within Normal Limits
Nasal mucosa, septum, and turbinates
WNL
Edema or erythema presentDentition and gums
WNL
Dental caries
GingivitisOropharynx
WNL
Edema or erythema present
Oral ulcers
Oral PetechiaeMallampati
I
II
III
IV
Neck
WNL = Within Normal Limits
Neck
WNL
Erythema or scarring consistent with
recent or
old radiation dermatitisThyroid
WNL
Thyromegaly
Nodules palpable
Neck mass _____________________ Jugular Veins
WNL
JVD present
a, v or cannon a waves present
Resp
WNL = Within Normal Limits
Chest is free of defects, expands normally and symmetrically
Erythema consistent with radiation dermatitis
Scarring consistent with old, healed radiation dermatitis
Surgical scar present
Scar, other Resp effort
WNL
Accessory muscle use
Intercostal retractions
Paradoxic movementsChest percussion
WNL
Dullness to percussion
Lt
Rt
Hyperresonance
Lt
RtTactile fremitus
WNL
Increased
Decreased
__________________________________ Auscultation
WNL
Bronchial breath sounds
Egophony
Rales
Rhonchi
Wheezes
Rub present
CV
WNL = Within Normal Limits
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
No peripheral edema Peripheral pulses
Absent
Weak
GI
WNL = Within Normal Limits
Abdomen
WNL Mass present
LUQ
RUQ
LLQ
RLQ ______________
Pulsatile
Liver and spleen palpation WNL Unable to palpate
Liver
Spleen Enlarged
Liver
Spleen
Lymph
(
2 areas must be examined)
WNL = Within Normal Limits
Lymph node exam WNL Areas examined
Neck
Axilla
Groin
Other ___________________ Lymphadenopathy noted in
Neck
Axilla
Groin
Other ___________________
Musc
WNL = Within Normal Limits
Muscle tone WNL, and no atrophy noted Tone is
Increased
Decreased
Atrophy present
Gait and station WNL
Ataxia
Wide based gait
Shuffle Patient leans
Rt
Lt
Front
Back
Extrem
WNL = Within Normal Limits
Exam wnl
Clubbing
Cyanosis
Petechiae
Synovitis
Rt
Lt ________________________
Skin
WNL = Within Normal Limits
No rashes, ecchymoses, nodules, ulcers
Rash
Bullae
Pressure Ulcer Stage
1
2
3
4
Neuro
WNL = Within Normal Limits
Oriented
NOT
oriented to
Person
Time
Place
Affect is WNL
OR
Patient appears
Agitated
Anxious
Depressed
Additional Findings Glasgow Coma Score E _____ V _____ M _____ APACHE II Score __________
al
S
se
seinates WNL
NLEdee
Dental caries Gin
GiEdema or erythema preo
r pr
II
IIII IV
mit
L
L
Erythema or scarriny
thmWNL
N
Thyromegalyo
ar Veins
WNL
NL
VDD
= With L
Chest is free of defec
es ee dScarring consrri
Resp efforte
hest percue
Tactile fr
T Aus
u
-
__ ____
SVR
SVR
esenters ral PetechiaeP
e recent or old radiatd ra
aable
Neck mass __
Nor cannon a waves prese
or n vesally and symmetricallym
allyaled radiation dermatitisd
dtitmuscle use
s
Intercos
rcDullness t
ss to percussion
o cus
Increased
eaDecrea
D
Bronchial breath sounr
nl b u
s
No murmur, rub or m
rupresent
t
Systolict
opheral pulses palpables
or Lim
Abdomen
n
WNL Ma Liver and spleen
iv d n
2 s
Lymph nodno
Lymph
y
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