Pneumonia Evaluation

Pneumonia 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 ✔

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Respiratory
Dyspnea ✔
Cough ✔
Phlegm ✔
Hemoptysis ✔ History of recent travel
Wheeze ✔ History of chemotherapy, use of immunosuppressive drugs, or immunosuppressive disease
Pleuritic Symptoms
Cardiovascular
Chest pain
Diaphoresis
Ankle edema
Syncope
Palpitations
Gastrointestinal
Nausea or vomiting
✔
✔
✔
✔
✔
✔
✔

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Allergies and Medications
Allergy List reviewed No drug allergies No food allergies
Medications reviewed Medications reconciled with Nursing Home data
Past Medical, Family Social History (PFSH)

Past Medical History
Asthma Diabetes Obstructive Sleep Apnea Other
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Weight changes ✔ COPD Hepatic Dysfunction Seizure Disorder
Diarrhea ✔
Congestive Heart Failure(CHF) HIV/AIDS Thyroid disease Hyper Hypo
Abdominal pain ✔ Coronary Artery Disease Hypertension Tuberculosis
Genitourinary
Hematuria ✔
Malignancy Yes No
Dysuria ✔
Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid
Urethral discharge
Treatment Surgical Resection Radioablation Chemotherapy Radiation
Musculoskeletal
Myalgias ✔
ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
Arthralgias ✔
Vaccines This patient is current on the following Seasonal Influenza Pneumococcal Varicella Pertussis Tetanus
Sa
Joint swelling ✔
Recent trauma
Surgeries CABG Cardiac valve replacement Splenectomy Organ transplant Joint replacement Other
Skin/Breasts
Masses
New skin lesions Social History Risk factors
Rash No ■
Yes Tobacco use Number Pack-Years _________
Neurologic
No
■ Yes Quit tobacco use Quit date _________
Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Headaches ✔
Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Seizures ✔
Numbness ✔ ■
No Yes Recreational drug use Route Inhalation Injection Ingestion
Paresthesias ■
No Yes Drug dependence Type Narcotics Benzodiazepines
Endocrinologic
Hair loss ✔ No ■
Yes Alcohol use ___ Drinks per Day Week
Polydipsia ✔
Occupational and Exposure History
Tremors ✔ Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Neck pain ✔ Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Heme/Lymph Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Bleeding gums ✔ Aerosolized water Source Hot tub Whirlpool baths High Pressure washings Other
Unusual bruising ✔ Pets or feathers
Swollen lymph nodes Chemicals or fires
Allergy/Immunology Military Experience
Nasal congestion ✔ Family History
Rhinorrhea ✔ Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Psychologic
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
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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
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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
Oriented NOT oriented to Person Time Place
Affect is within normal limits OR Patient appears Agitated Anxious Depressed
Additional Findings
Radiology
CXR CT/Chest Other
Medical Decision Making 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
Previous radiographic imaging data
ECHO This patient has advanced health care directives. Their HCPOA is
Pulmonary Function Test
Care Coordinated with
Patient
HCPOA / Surrogate
Other physician or Consultant
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Recommended Diagnostics
CBC with differential
PT, PTT, INR
Metabolic Panel Basic Complete
HIV
Quantiferon

Urine for Histoplasma and Legionella
Serum mycoplasma

Culture, Sputum
Culture, Blood

pl
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Chest CT (Computed Tomography)
ECHO
Bronchoscopy
Pneumonia Severity Index
Age
Male Age (in years) 0
Female Age (in years) - 10 0
NH resident Age (in years) +10 0
Sa
Comorbid illnesses
Neoplastic disease 0
Liver disease 0
CHF 0 Signature Physician Resident C-FNP PA-C
Cerebrovascular disease 0
Renal disease 0
Physical exam findings

0
Altered mental status
Respiratory rate >/= 30 0
Systolic BP < 90 0
Temp < 35 degrees or > 40 0
Pulse > 124 0
Lab Findings
pH <7.35 0
BUN >10.7 mmol/L 0
Sodium <130 mEq/L 0
Glucose > 13.9 mmol/L 0
Hematocrit <30 percent 0
pO2 <60 mmHg 0
Pleural effusion 0
Risk Class Total 0

Low I Algorithm I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the Resident,
NP or PA above and I agree with the assessment and plan as outlined.
Low II < 71 points
Low III 71-90 points Supervising Physician Signature
Moderate IV 91-130 points cc
High V >130 points

Pneumonia Evaluation

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Pneumonia Evaluation

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Pneumonia Evaluation Patient Name DOB MRN Date

Medications reviewed Medications reconciled with Nursing Home data

Past Medical, Family Social History (PFSH)

Date of Intubation ________________

Physical exam findings

Risk Class Total 0

You might also like

Pneumonia Evaluation

Uploaded by

Document Information

Copyright

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Share this document

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Sharing Options

Did you find this document useful?

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Pneumonia Evaluation

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Copyright:

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Pneumonia Evaluation Patient Name DOB MRN Date

Medications reviewed Medications reconciled with Nursing Home data

Past Medical, Family Social History (PFSH)

Date of Intubation ________________

Physical exam findings

Risk Class Total 0

You might also like

Medications reviewed Medications reconciled with Nursing Home data