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Pleural Effusion Evaluation

Pleural Effusion Evaluation

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Published by e-MedTools
The pleural effusion evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with pleural effusions.

A pleural effusion is a collection of excess fluid in the pleural space which is between the lungs and the chest wall. Chest pain and difficulty breathing are the most common symptoms.

Pleural effusions are concerning because they can indicate the presence of malignancies, such as lung cancer, lymphoma, metastatic cancer, or rarely, mesothelioma. Fortunately, the most common causes of pleural effusions are a wide range of treatable medical conditions such as congestive heart failure (CHF), pneumonia, pancreatitis, lupus, kidney disease, liver disease, tuberculosis, and others. Because so many medical conditions can be associated with pleural effusions, it can be difficult to positively determine the etiology.

Determining the cause of the pleural effusion requires a detailed medical and occupational history that includes outside interests, such as hobbies, and a complete physical exam. All new pleural effusions of substantial volume must be evaluated by a thoracentesis. This is done by inserting a needle or tube into the pleural fluid, and sending the fluid for laboratory analysis. Laboratory analysis includes evaluation of the presence of bacteria, inflammatory cells, cancer cells, proteins indicative of tuberculosis, esophageal rupture or urinothorax, or antibodies indicative of autoimmune disease.

The pleural effusion evaluation medical template provides historical and laboratory prompters for the physician, facilitating a thorough and efficient investigation. Much of the documentation is done by clicking on checkboxes. Text boxes are provided to facilitate individualized documentation of the history, physical exam and impression and plan.
The pleural effusion evaluation MedicalTemplate is suitable for any health care provider that evaluates patients with pleural effusions.

A pleural effusion is a collection of excess fluid in the pleural space which is between the lungs and the chest wall. Chest pain and difficulty breathing are the most common symptoms.

Pleural effusions are concerning because they can indicate the presence of malignancies, such as lung cancer, lymphoma, metastatic cancer, or rarely, mesothelioma. Fortunately, the most common causes of pleural effusions are a wide range of treatable medical conditions such as congestive heart failure (CHF), pneumonia, pancreatitis, lupus, kidney disease, liver disease, tuberculosis, and others. Because so many medical conditions can be associated with pleural effusions, it can be difficult to positively determine the etiology.

Determining the cause of the pleural effusion requires a detailed medical and occupational history that includes outside interests, such as hobbies, and a complete physical exam. All new pleural effusions of substantial volume must be evaluated by a thoracentesis. This is done by inserting a needle or tube into the pleural fluid, and sending the fluid for laboratory analysis. Laboratory analysis includes evaluation of the presence of bacteria, inflammatory cells, cancer cells, proteins indicative of tuberculosis, esophageal rupture or urinothorax, or antibodies indicative of autoimmune disease.

The pleural effusion evaluation medical template provides historical and laboratory prompters for the physician, facilitating a thorough and efficient investigation. Much of the documentation is done by clicking on checkboxes. Text boxes are provided to facilitate individualized documentation of the history, physical exam and impression and plan.

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Published by: e-MedTools on Sep 08, 2008
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07/31/2013

 
Pleural Effusion Evaluation
©MB and RR 2006, 2007 Revised 24April07
MRNDate Start time Stop time
 Allergies Chief complaint/Reason for consult
MedicationsHistory of present illness
Pleuritic chest pain present
Recent severe emesis or esophageal dilatation
Dyspnea or cough
Recent MI or cardiothoracic surgery
Peripheral edema
CHF, ESRD on HD, SLE, RA, Sarcoidosis
Orthopnea or PND
History of asbestos exposure
Decreased exercise tolerance
History of malignancy
Recent fever, chills or nightsweats
Drugs associated with pleural effusion include, but are not limited to: bromocriptine, cyclophosphamide, dantrolene, isotretinoin,mesalamine, methotrexate, mitomycin, nitrofurantoin, practolol, procarbazine
Social HistoryReview of Systems
Tobacco use ____ Packs x ____ Yrs
Quit
Daily, occasional and ex-smokers aremore likely to be hazardous drinkers
Alcohol use ______ Drinks per 

day
week
Hazardous drinking 
NIAAA (National Institute on Alcoholism and Alcohol Abuseguidelines)
 
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 
Recreational drug use
See HPI WNL

Constitutional
Fatigue, malaise, fever/chills, weight loss, change in appetite

Eyes
Vision changes, New pain, Scotomas

ENT/mouth
Nose bleeds, dental caries, dental abscesses, jaw pain

Resp
Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea

CV
Chest pain, diaphoresis, ankle edema, PND, syncope

GI
Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena

GU
Change in urinary habits, hematuria, dysuria

Musc
Myalgias, recent trauma, bony fractures, arthralgias, joint swelling

Skin/breasts
Rashes, new masses or skin lesions, increased sensitivity to sun

Neuro
Seizures, episodic or chronic muscle weakness

Endo
Hair loss, polydipsia

Heme/lymph
Bleeding gums, unusual bruising, swollen lymph nodes

Allergy/Immun
Sinus probs, recurrent infections

Psych
Mood changes, agitation, psychosis, delirium, dementia
Notes
Family Medical History Past Medical and Surgical History
Congestive Heart Failure
Coronary Artery Disease
Malignancy
Pancreatitis
Renal Dysfunction
Thyroid Disease
Asthma
Cerebral Artery Disease
Neuromuscular weakness
Chemotherapy
Bronchiectasis
Congestive Heart Failure
Occupational exposures
Colonoscopy
COPD
Coronary Artery Disease
Pancreatitis
ECHO/Stress Test
COP (BOOP)
Diabetes
Peripheral Artery Disease
Mammogram
Cystic Fibrosis
GERD
Scleroderma
PFTs
Histiocytosis
Hepatic Dysfunction
Seizure Disorder 
PapSmear 
Tuberculosis
HIV/AIDS
Sjogren
Prior Intubations
PAH
Hypertension
Renal Dysfunction
Radiation exposure
Sarcoidosis
Inflam bowel disease
Rheumatoid arthritis
Sleep Study
Tuberculosis
Malignancy
Thrombotic Disease
Steroid use
Thyroid Disease
Notes

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