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
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