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Interstitial Lung Disease Evaluation

Interstitial Lung Disease Evaluation

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Published by e-MedTools
The interstitial lung disease evaluation MedicalTemplate is suitable for any health care provider who may evaluate a patient with interstitial lung disease.

Interstitial Lung Disease (ILD) is a diverse group of more than 200 diseases that cause progressive fibrosis (scarring) of lung tissue, which leads to chronic, progressive breathlessness and respiratory failure. The Pulmonary Fibrosis Foundation (www.pulmonaryfibrosis.org) estimates that more than 200,000 Americans have ILD, and nearly 40,000 Americans die each year from ILD.

ILD includes idiopathic pulmonary fibrosis (IPF), sarcoidosis, hypersensitivity pneumonitis, Nonspecific Interstitial Pneumonitis (NSIP), Desquamative
Interstitial Pneumonitis (DIP), Cryptogenic Organizing Pneumonia (COP, aka BOOP), medication induced lung disease, post-radiation fibrosis, and many other diseases.

The primary symptoms of ILD are nonspecific, such as non-productive cough and progressive breathlessness. These symptoms are seen in many other medical conditions such as asthma, heart failure, or chronic obstructive pulmonary disease (COPD). The lack of specificity of the presenting symptoms makes the identification of ILD challenging, particularly in individuals with known heart or lung disease. Early and accurate diagnosis of ILD is essential so that treatment options can be considered before extensive and permanent damage occurs, resulting in disabling breathlessness. While there is currently no proven, FDA-approved treatment for idiopathic pulmonary fibrosis, many forms of interstitial lung disease can be treated, if detected early in the disease process. Thus, having a low threshold for suspecting interstitial disease, and assessing a patient’s risk of developing pulmonary fibrosis by obtaining important historical information is critical to early diagnosis.
The interstitial lung disease evaluation MedicalTemplate is suitable for any health care provider who may evaluate a patient with interstitial lung disease.

Interstitial Lung Disease (ILD) is a diverse group of more than 200 diseases that cause progressive fibrosis (scarring) of lung tissue, which leads to chronic, progressive breathlessness and respiratory failure. The Pulmonary Fibrosis Foundation (www.pulmonaryfibrosis.org) estimates that more than 200,000 Americans have ILD, and nearly 40,000 Americans die each year from ILD.

ILD includes idiopathic pulmonary fibrosis (IPF), sarcoidosis, hypersensitivity pneumonitis, Nonspecific Interstitial Pneumonitis (NSIP), Desquamative
Interstitial Pneumonitis (DIP), Cryptogenic Organizing Pneumonia (COP, aka BOOP), medication induced lung disease, post-radiation fibrosis, and many other diseases.

The primary symptoms of ILD are nonspecific, such as non-productive cough and progressive breathlessness. These symptoms are seen in many other medical conditions such as asthma, heart failure, or chronic obstructive pulmonary disease (COPD). The lack of specificity of the presenting symptoms makes the identification of ILD challenging, particularly in individuals with known heart or lung disease. Early and accurate diagnosis of ILD is essential so that treatment options can be considered before extensive and permanent damage occurs, resulting in disabling breathlessness. While there is currently no proven, FDA-approved treatment for idiopathic pulmonary fibrosis, many forms of interstitial lung disease can be treated, if detected early in the disease process. Thus, having a low threshold for suspecting interstitial disease, and assessing a patient’s risk of developing pulmonary fibrosis by obtaining important historical information is critical to early diagnosis.

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Published by: e-MedTools on Sep 08, 2008
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09/06/2012

 
Interstitial Lung DiseaseEvaluation
Patient Name DOB MRN Encounter Date
©MB and RR 2011 e-medtools.com Revised23Feb2011 Health Care Provider Signature
Review of SystemsChief complaint/Reason for consult
Start Time Stop Time
 YesNoConstitution
Fatigue or Malaise
Fever or chills
 Appetite changes
Eyes
Conjunctivitis
New eye painBlurred vision
ENT/mouth
Sore throatSwollen uvulaJaw pain
Respiratory
DyspneaCoughPhlegmHemoptysisWheeze
Cardiovascular 
Chest painDiaphoresis Ankle edemaSyncopePalpitations
Gastrointestinal
Nausea or vomitingWeight changesDiarrhea Abdominal pain
Genitourinary
HematuriaDysuriaUrethral discharge
Musculoskeletal
Myalgias ArthralgiasJoint swellingRecent trauma
Skin/Breasts
MassesNew skin lesionsRash
Neurologic
HeadachesSeizuresMuscle weaknessParesthesias
Endocrinologic
Hair lossPolydipsiaTremorsNeck pain
Heme/Lymph
Bleeding gumsUnusual bruisingSwollen lymph nodes
Allergy/Immunology
Nasal congestionRhinorrhea
Psychologic
 AgitationHallucinations
History of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Chronic, progressive dyspnea over >/= 1 year 
Chronic cough with or without phlegm production
History of fever, chills, nightsweats, myalgias, arthralgias
Fatigue, chronic and progressive over same period as dyspnea
Increased interstitial markings on >/= 2 radiographs, 1 month apart (not related to renal or heart failure)
History of medication use associated with pulmonary fibrosis
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 waterSource
Hot tub
Whirlpool baths
High Pressure washings
Other 
Pets or feathers
Chemicals or fires
Military Experience
Allergies and Medications
 Allergy List reviewed
No drug allergies
No food allergies
History of life threatening allergic response to
Medications reviewed
Medications reconciledwith Nursing Home data
Past Medical History, Social History and Family 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
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
Cardiac valve replacement
Splenectomy
Organ transplant
Joint replacement
Other 
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
Pneumococcal
Varicella
Pertussis
Tetanus
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
Family Medical History
 Asthma
Coronary Artery Disease
Renal Dysfunction
Malignancy
CHF
Pancreatitis
Thrombotic disorder 
Other 
COPD
Peripheral Artery Disease
Thyroid Disease
  S  a  m  p   l  e
 
Interstitial Lung DiseaseEvaluation
Patient Name DOB MRN Encounter Date
©MB and RR 2011 e-medtools.com Revised23Feb2011 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
 ____ 
PEEPlevel
 ______ 
 Pressure Support level
 ______ 
Peak Inspiratory Pressure
 ______ 
Plateau Pressure
 ______ 
ARDS ALIPO2/FiO2
<200
201-300
>300
Labs
 \____/ ____ / ____ / ____ // \ \ \ \
Radiology
CXR
CT scan
Other 
Constitutional
Body habitus
WNL
Cachectic
ObeseGrooming
WNL
Unkempt
ENT
Nasal mucosa, septum, and turbinates
Within normal limits
Edema or erythema presentDentition and gums
Within normal limits
Dental caries
GingivitisOropharynx
Within normal limits
Edema or erythema present
Oral ulcers
Oral PetechiaeMallampati
I
II
III
IV
Neck
Neck
Within normal limits
Erythema or scarring consistent with
recent or 
old radiation dermatitisThyroid
Within normal limits
Thyromegaly
Nodules palpable
Neck mass _____________________ Jugular Veins
Within normal limits
JVD present
a, v or cannon a waves present
Resp
Chest is free of defects, expands normally and symmetrically
Erythema consistent with radiation dermatitis
Scarring consistent with old, healed radiation dermatitisResp effort
Within normal limits
 Accessory muscle use
Intercostal retractions
Paradoxic movementsChest percussion
Within normal limits
Dullness to percussion
Lt
Rt
Hyperresonance
Lt
RtTactile exam
Within normal limits Tactile fremitus
Increased 
Decreased 
 ________________________  Auscultation
Within normal limits

Bronchial breath sounds
Egophony
Rales
Rhonchi
Wheezes
Rub present
CV
Clear S1 S2
No murmur, rub or gallop
Gallop
Rub
Murmur present
Systolic
Diastolic
Grade
I
II
III
IV
V
VI
Peripheral pulses palpable
No peripheral edema Peripheral pulses
 Absent
Weak
GI
 Abdomen
Within normal limits 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)
Lymph node exam wnl Areas examined
Neck
 Axilla
Groin
Other ___________________ Lymphadenopathy noted in
Neck
 Axilla
Groin
Other ___________________ 
Musc
Muscle tone within normal limits, 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
Exam wnl
Clubbing
Cyanosis
Petechiae
Synovitis
Rt
Lt ________________________ 
Skin
No rashes, ecchymoses, nodules, ulcers
Neuro
Oriented
NOT
oriented to
Person
Time
Place
 Affect is within normal limits
OR 
Patient appears
 Agitated
 Anxious
Depressed
Additional Findings
  S  a  m  p   l  e

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