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Pneumonia Evaluation

Pneumonia Evaluation

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Published by e-MedTools
The pneumonia evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers that evaluate patients with known or suspected pneumonia in ambulatory or hospital settings. This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with pneumonia.

The Pneumonia Evaluation MedicalTemplate contains prompters for ascertaining different symptoms associated with pneumonia, such as dyspnea, chest pain, pleuritic pain, cough, fever, chills, nightsweats, and hemoptysis. Other prompters help identify patients who are at higher risk of aspiration pneumonia, multi-drug resistant infections, or infections due to less common causes including fungus, legionella, SARS, avian influenza, tuberculosis, and other microbes. Questions to document smoking history, drug abuse (both prescription and street drugs), and alcohol abuse are included to identify patients who are at increased risk of certain types of pneumonia.

Differentiating pneumonia from other medical conditions that produce a similar appearance on a chest x-ray challenging. The Pneumonia Evaluation MedicalTemplate includes prompters to help identify patients who may have other medical conditions such as myocardial infarction, heart failure, vasculitis, inhalation injury, or esophageal rupture that can cause produce a pneumonia like appearance on chest x-ray.
The pneumonia evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers that evaluate patients with known or suspected pneumonia in ambulatory or hospital settings. This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with pneumonia.

The Pneumonia Evaluation MedicalTemplate contains prompters for ascertaining different symptoms associated with pneumonia, such as dyspnea, chest pain, pleuritic pain, cough, fever, chills, nightsweats, and hemoptysis. Other prompters help identify patients who are at higher risk of aspiration pneumonia, multi-drug resistant infections, or infections due to less common causes including fungus, legionella, SARS, avian influenza, tuberculosis, and other microbes. Questions to document smoking history, drug abuse (both prescription and street drugs), and alcohol abuse are included to identify patients who are at increased risk of certain types of pneumonia.

Differentiating pneumonia from other medical conditions that produce a similar appearance on a chest x-ray challenging. The Pneumonia Evaluation MedicalTemplate includes prompters to help identify patients who may have other medical conditions such as myocardial infarction, heart failure, vasculitis, inhalation injury, or esophageal rupture that can cause produce a pneumonia like appearance on chest x-ray.

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Published by: e-MedTools on Sep 08, 2008
Copyright:Traditional Copyright: All rights reserved

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07/10/2013

 
PneumoniaEvaluation
Patient Name DOB MRN Date
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 Health Care Provider Signature
Review of SystemsChief complaint/Reason for consult
Start Time Stop Time
Review of SystemsYesNoConstitution
Fatigue or Malaise
Fever or chills
 Appetite changes
Eyes
Conjunctivitis
New eye painBlurred vision
ENT/mouth
Sore throatSwollen uvulaJaw pain
Respiratory
DyspneaCoughPhlegmHemoptysisWheezePleuritic Symptoms
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
HeadachesSeizuresNumbnessParesthesias
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
History of recent travel
History of chemotherapy, use ofimmunosuppressive drugs, or immunosuppressive disease
Allergies and Medications
 Allergy List reviewed
No drug allergies
No food allergies
Medications reviewed
Medications reconciledwith Nursing Home data
Past Medical, Family SocialHistory(PFSH)
Past MedicalHistory
 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
Malignancy
Yes
No
 
 Adrenal
Breast
Colon
Leuk/Lymph
Lung
Melanoma
Renal cell
Skin
Pituitary
Prostate
Testicular 
Thyroid
Treatment 
Surgical Resection
Radioablation
Chemotherapy 
Radiation
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
Surgeries
CABG
Cardiac valve replacement
Splenectomy
Organ transplant
Joint replacement
Other 
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
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
Family 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
 
 
PneumoniaEvaluation
Patient Name DOB MRN Date
©MB and RR 2006-2011 e-medtools.com Revised 23Feb2011 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/Chest
Other 
Constitutional
Body habitus
WNL
Cachectic
ObeseGrooming
WNL
Unkempt
ENT
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
Neck
WNL
Erythema or scarring consistent with
recent or 
old radiation dermatitisThyroid
WNL
Thyromegaly
Nodules palpable
Neck massJugular Veins
WNL
JVD present
a, v or cannon a waves present
Respiratory
 Chest
Free of defects, expands normally and symmetrically
Erythema consistent with radiation dermatitisScarring consistent with
Old, healed radiation dermatitis
Prior surgery
Trauma
Other Respiratoryeffort
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
Cardiovascular 
Heartsounds
Clear S1 S2
No murmur, rub or gallop
Gallop audible
Rub audible

Murmur present
Systolic
Diastolic
Grade
I
II
III
IV
V
VIPeripheral pulses
Palpableand symmetric
 Absent
WeakPeripheral edema
 Absent
Present
Gastrointestinal 
 Abdomen
WNL
Mass present
LUQ
RUQ
LLQ
RLQ
PulsatileLiver 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 Lymphadenopathy noted
Neck
Submental
 Axillary
Epitrochlear 
Inguinal
Other 
Musculoskeletal
Muscle tone
WNL, and no atrophy noted
Increased
Decreased
 Atrophy presentGait and station
WNL
 Ataxia
Wide based gait
Shuffle Patient leans
Rt
Lt
Front
Back
Extremities
Exam
WNL
Clubbing
Cyanosis
Petechiae
Synovitis
Rt
Lt
Skin
Exam
WNL
Rash
Ecchymosis
Nodules
Ulcer 
Neurologic
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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