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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
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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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