Lung Mass Evaluation

Lung Mass Evaluation Patient Name DOB MRN Date
Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Review of Systems Yes No
Constitution
Fatigue or Malaise
Fever or chills
History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes
Conjunctivitis
New eye pain

Blurred vision
ENT/mouth

Sore throat
Swollen uvula
Jaw pain

e
Respiratory
Dyspnea History of recent travel
Cough History of chemotherapy, use of immunosuppressive drugs, or immunosuppressive disease
Phlegm
Allergies and Medications
Hemoptysis
Wheeze Allergy List reviewed No drug allergies No food allergies

Pleuritic Symptoms
Cardiovascular
Chest pain
Diaphoresis
Ankle edema
Syncope
Palpitations
Gastrointestinal
Nausea or vomiting
COPD
pl
Medications reviewed Medications reconciled with Nursing Home data
Past Medical, Family Social History (PFSH)

Past Medical History
Asthma
Congestive Heart Failure(CHF)

Coronary Artery Disease
Diabetes
Hepatic Dysfunction
HIV/AIDS
Hypertension
Obstructive Sleep Apnea
Seizure Disorder
Thyroid disease Hyper Hypo
Tuberculosis
Other
m
Weight changes
Diarrhea Malignancy Yes No
Abdominal pain Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid
Treatment Surgical Resection Radioablation Chemotherapy Radiation
Genitourinary
Hematuria
Dysuria ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
Urethral discharge Vaccines This patient is current on the following Seasonal Influenza Pneumococcal Varicella Pertussis Tetanus
Musculoskeletal
Myalgias Surgeries
Arthralgias Appendectomy Cholecystectomy Pacemaker Organ transplant
Sa
Joint swelling Arterial bypass Colon resection Defibrillator

Recent trauma Coronary Artery Bypass Hysterectomy Other
Skin/Breasts Cardiac valve repair or replace Nephrectomy Hip replacement
Masses Carotid Endarterectomy Splenectomy Knee replacement
New skin lesions
Social History Risk factors
Rash
No Yes Tobacco use Number Pack-Years _________
Neurologic No Yes Quit tobacco use Quit date _________
Headaches
Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Seizures Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Numbness
Paresthesias No Yes Recreational drug use Route Inhalation Injection Ingestion
Endocrinologic No Yes Drug dependence Type Narcotics Benzodiazepines
Hair loss
No Yes Alcohol use ___ Drinks per Day Week
Polydipsia
Tremors Occupational and Exposure History
Neck pain Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Heme/Lymph Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Bleeding gums Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Unusual bruising Aerosolized water Source Hot tub Whirlpool baths High Pressure washings Other
Swollen lymph nodes Pets or feathers
Allergy/Immunology Chemicals or fires
Nasal congestion
Military Experience
Rhinorrhea Family History
Psychologic Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Agitation CHF Pancreatitis Thrombotic disorder Other
Hallucinations
COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Exam WNL = Within Normal Limits
Vitals Constitutional
Height _______ in cm Body habitus WNL Cachectic Obese
Grooming WNL Unkempt
Weight _______ lb kg ENT
WNL Edema or erythema present
Nasal mucosa, septum, and turbinates
Temperature _______ C F Dentition and gums WNL Dental caries
Gingivitis
Oropharynx WNL Edema or erythema present Oral ulcers Oral Petechiae
Pulse Rate _______
Rhythm Regular Irregular Mallampati I II III IV
Neck
Blood Pressure ____________ Neck WNL Erythema or scarring consistent with recent or old radiation dermatitis
Sitting Standing Lying Thyroid WNL Thyromegaly Nodules palpable Neck mass
e
Jugular Veins WNL JVD present a, v or cannon a waves present
Oxygen Saturation (Pulse oximetry) Respiratory
Chest Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
_______ Rest Exercise
Scarring consistent withOld, healed radiation dermatitis Prior surgery Trauma Other
Rest Exercise Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements
_______
NonInvasive Ventilator
CPAP BiPAP Ins ____
Ventilator
Mode ACSIMVPCPRVC
Exp ____
Date of Intubation ________________

Cardiovascular
pl
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
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
m
Peripheral edema Absent Present
Endotracheal Tube Size _____ Gastrointestinal
Tracheostomy Tube Size _____
Abdomen WNL Mass present LUQ RUQ LLQ RLQ Pulsatile
Rate ____ Tidal Vol ____ FiO2 ____ Liver and spleen Palpable and WNL Unable to palpate Liver
Spleen Organomegaly Liver Spleen
Lymphatics (2 areas must be examined)
Lymph node exam WNL Areas examined Neck Axilla Groin Other
PEEP level ______
Pressure Support level ______
Lymphadenopathy noted Neck Submental Axillary Epitrochlear Inguinal Other
Peak Inspiratory Pressure ______ Musculoskeletal
Plateau Pressure ______
Muscle tone WNL, and no atrophy noted Increased Decreased Atrophy present
Sa
ARDS ALI Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
PO2/FiO2 <200 201-300 >300 Extremities
Exam WNL Clubbing Cyanosis Petechiae Synovitis Rt Lt
Labs
Skin
\____/ ____ / ____ / ____ / Exam WNL Rash Ecchymosis Nodules Ulcer
/ \ \ \ \ Neurologic
Orientation Oriented NOT oriented to Person Time Place
Cranial Nerves Intact
Deficit noted CN II
III IV V VI VII VIII IX X XI XII
Deep Tendon Reflexes Appropriate and symmetric Babinski present Other
Sensation Intact Deficit noted in Touch Pin Vibration Proprioception
Radiology
CXR CT/Chest Other
Additional Findings
Impression and Plan
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
ER Notes decision maker) understands their medical condition, their prognosis and the consequences of their Code
Status decision.
Old medical records
Code Status Patient is a FULL CODE DO NOT ATTEMPT Cardiac Resuscitation DO NOT Intubate
Labs
Previous radiographic imaging data This patient has advanced health care directives. Their HCPOA is
Pathology
ECHO
ECG
Stress Test
Pulmonary Function Test
e
Care Coordinated with
Patient
HCPOA / Surrogate
Other physician or Consultant
Case Management or Social Worker
Pharmacy
Nursing
Recommended Diagnostics
CBC with differential
PT, PTT, INR
Metabolic Panel
HIV

pl
m
PPD
Quantiferon
Sputum Cytology
Urine for Histoplasma and Legionella
Cultures
Sputum
Bacterial Fungal AFB
Blood
Sa
Urine
CSF
Signature Physician Resident C-FNP PA-C
Computed Tomography (CT)
Chest Abdomen/Pelvis Head Neck

Positron Emission Tomography (PET)

ECG
ECHO
Bronchoscopy
Transthoracic Needle Biopsy
Cardiothoracic Surgery Consult
Other
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.
Supervising Physician Signature

cc

Lung Mass Evaluation

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lung Mass Evaluation

Uploaded by

Copyright:

Available Formats

Lung Mass Evaluation Patient Name DOB MRN Date

Past Medical, Family Social History (PFSH)

Congestive Heart Failure(CHF)

Joint swelling Arterial bypass Colon resection Defibrillator

Date of Intubation ________________

Supervising Physician Signature

You might also like

Lung Mass Evaluation

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lung Mass Evaluation

Uploaded by

Copyright:

Available Formats

Lung Mass Evaluation Patient Name DOB MRN Date

Past Medical, Family Social History (PFSH)

Congestive Heart Failure(CHF)

Joint swelling Arterial bypass Colon resection Defibrillator

Date of Intubation ________________

Supervising Physician Signature

You might also like

Congestive Heart Failure(CHF)

Joint swelling Arterial bypass Colon resection Defibrillator