Pulmonary Evaluation www.e-medtools.

com
Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Date Time Chief complaint/Reason for consult Referring MD
Yes No
Constitution Reset

Fatigue History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Malaise Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms
Fever or chills
Appetite changes
Eyes Reset

Vision changes
New pain
Scotomas
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ENT/mouth Reset

Nose bleed
Dental caries
Dental abscesses
Jaw pain
Respiratory Reset

Dyspnea Medications Allergies

Cough Medications reviewed Allergy List reviewed
Phlegm Medications reconciled with Nursing Home or Hospital discharge Information 46 No food or drug allergies
Hemoptysis
Wheeze Past Medical, Family Social History
Cardiovascular
Chest pain
Reset
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Asthma Cerebral Artery Disease Neuromuscular weakness Chemotherapy
Bronchiectasis Congestive Heart Failure Occupational exposures Colonoscopy
Diaphoresis
COPD Coronary Artery Disease Osteoporosis ECHO/Stress Test
Ankle edema
COP (BOOP) Diabetes Pancreatitis Mammogram
Syncope
Cystic Fibrosis GERD Peripheral Artery Disease PFTs
Palpitations
Histiocytosis Hepatic Dysfunction Scleroderma PapSmear
Gastrointestinal Reset

Nausea or vomiting Tuberculosis HIV/AIDS Seizure Disorder Prior Intubations

Weight changes PAH Hypertension Sjogren’s Radiation exposure
Constipation or Sarcoidosis Inflam bowel disease Renal dysfunction/ failure Sleep Study
Diarrhea Wegener’s Malignancy Rheumatoid Arthritis Steroid use
Abdominal pain Obstructive Sleep Apnea Thrombotic Disease
Genitourinary Reset
CPAP BiPAP Thyroid disease
Urinary changes
Hematuria
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Malignancy
Adrenal Colon Melanoma Renal cell Thyroid Breast Lung Prostate Testicular
Dysuria
Urethral discharge Surgeries
Musculoskeletal Reset

Myalgias
Arthralgias Social History / Risk factors
Joint swelling Denies Yes Ever smoker ___ # Packs X ____ # Yrs Denies Yes Patient has tried smoking cessation aids
Recent trauma Denies Yes Chews tobacco Nicotine replacement
Skin/Breasts Reset Denies Yes Quit tobacco use Quit date _________ Buproprion or nortriptyline
Masses Patient is unwilling to quit Nicotine receptor blockade
New skin lesions Patient willing to consider quitting
Patient quit, but resumed smoking
Rashes
Patient willing to quit within 1 month
Sensitivity to sun
Neurologic Reset
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Denies Yes Feels safe at home or work Denies Yes Alcohol use ___ Drinks per day week
Headaches
Denies Yes Tattoos Denies Yes Felt the need to cut down on drinking?
Seizures Denies Yes High risk sexual behavior Denies Yes Annoyed by others criticizing drinking?
Muscle weakness Denies Yes Recreational drug use Denies Yes Guilt associated with drinking?
Endocrinologic Reset
Inhalational Injectable Ingestible Denies Yes Eye opener needed?
Hair loss Denies Yes Drug dependence
Polydipsia Narcotics Benzodiazepines
Tremors
Neck pain Occupational and Exposure History
Heme/Lymph Reset 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
Bleeding gums
Unusual bruising
Swollen lymph nodes
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Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Hot tub or Jacuzzi or High Pressure washings
Pets or feathers
Allergy/Immunology Reset
Chemicals or fires
Sinus problems
Recurrent infections Family Medical History
Psychologic Reset
Asthma CHF COPD Coronary Artery Dis Pancreatitis Peripheral Artery Disease Renal Dysfunction
Mood changes
Thrombotic disorder Thyroid Disease
Agitation
Malignancy in first degree relatives, specify
Hallucinations

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary Evaluation www.e-medtools.com
Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Exam To qualify as a comprehensive exam: General Multisystem requires performing ALL of ≥9 organ systems, AND ≥2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND ≥1 element in every other organ system is expected
Ventilator, IV Medications & Labs Constitutional (≥ 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam

Ventilator Height ___________ in cm Weight ___________ lb kg

Mode AC SIMV PC Temperature __________ Pulse Rate __________ AND Rhythm Regular Irregular
PRVC Other ____________
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Blood Pressure sitting __________ / __________ OR standing __________ / __________
Rate __________
Blood Pressure lying __________ / __________
Tidal Vol __________
Respiratory Rate__________ Optional Sats _____ % Cardiac Output _____ SVR _____
PEEP __________
Body habitus wnl Cachectic Obese
PS __________
Grooming wnl Unkempt
ENT
FiO2 __________
Nasal mucosa, septum, and turbinates wnl
PO2/FiO2__________ Dentition and gums wnl Dental caries Gingivitis

Plateau __________ www.e-medtools.com

Oropharynx wnl
Mallampati I II
Oropharyngeal edema or erythema
III IV
Oral ulcers Oral Petechiae

NonInvasive Ventilator Neck

CPAP BiPAP Neck wnl Erythema or scarring consistent with Recent Old radiation dermatitis
Thyroid wnl Thyromegaly Thyroid nodules palpable Neck mass ___________________________
IV Medications
Pressors Dose Rate Jugular Veins wnl JVD present a, v or cannon a waves present
____________________________
Resp
____________________________ Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Antihypertensives Scarring consistent with old, healed radiation dermatitis
____________________________ Respiratory effort is wnl Accessory respiratory muscle use Intercostal retractions
Diuretics
____________________________
Antibiotics
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Chest percussion wnl
Paradoxic diaphragmatic movements
Dullness to percussion Lt Rt Hyperresonance Lt Rt
____________________________ Tactile exam wnl Tactile fremitus Increased Decreased _____________________________________
Clear to auscultation Bronchial breath sounds Egophony (E to A) Rales Rhonchi Wheezes
____________________________
Rub present ________________________
Sedation
CV
____________________________
Clear S1 S2 No murmur, rub or gallop Gallop Rub
Narcotics
____________________________ Murmur present Systolic Diastolic Grade I II III IV V VI
Heparin Peripheral pulses palpable No peripheral edema Peripheral pulses Absent Weak
____________________________ GI
Insulin Abdominal exam wnl Mass present LUQ RUQ LLQ RLQ ____________________ Pulsatile
____________________________
Antiarrhythmics
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Liver and spleen palpation wnl Unable to palpate
Lymph (≥2 areas must be examined)
Liver Spleen Enlarged Liver Spleen

____________________________
Lymph node exam wnl Areas examined Neck Axilla Groin Other ___________________
Steroids
____________________________ Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Musc
Paralytic
____________________________ Muscle tone within normal limits, and no atrophy noted
Thrombolytic Tone is Increased Decreased Atrophy present
____________________________ Gait and station wnl
TPN Ataxia Wide based gait Shuffle Patient leaning Rt Lt Front Back

Labs www.e-medtools.com
Extrem
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
\____/ Skin
/ \ No rashes, ecchymoses, nodules, ulcers Periungual telangiectasias Splinter hemorrhages
Neuro
____ / ____ / ____ /
Oriented 58(Pts with Community Acquired Bacterial Pneumonia) NOT oriented to Person Time Place
\ \ \
Affect is within normal limits OR Patient appears Agitated Anxious Depressed

Glasgow Coma Score E _____ V _____ M _____ APACHE II Score __________

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary Evaluation
Data Reviewed
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Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________
Impression
ER Notes Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
Old medical records Patient has completed advanced health care directives 47
Labs HCPOA is _______________________________________
Radiology data
ECHO
ECG
Stress Test
Pulmonary Function Test
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Nursing Notes/Vitals log

Care Coordinated with

Patient
HCPOA / Surrogate
PCP
Consultant
Case Management or Social Worker
Pharmacy
Nursing
Physical Therapist
Occupational Therapist
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Speech Therapist

Recommended Actions
Aggressive pulmonary toilet
DVT prophylaxis
Stress ulcer prophylaxis
Daily sedation vacation and
neurologic assessment
Head of bed elevated > 30 Degrees
at all times
Intense glycemic control
Insulin infusion
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Central line change or removal
(send tip for culture)
Physical therapy
Enteral/Parenteral feeds
Smoking cessation aids
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge

Recommended Diagnostics
PPD Testing
12-lead EKG www.e-medtools.com
Echocardiogram

Sputum culture
Bacterial Fungal AFB

Blood culture

Urine culture

CSF culture
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CBC with differential
PT, PTT, INR
BMP (with calcium)
HIV
Hepatitis panel
Signature ________________________________________ cc __________________________________

©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services
Pulmonary and Critical Care New Patient Evaluation Template
Definitions
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Date Start time Stop time
Physiologic Score
APACHE II Score - To be obtained within first 24 hours of ICU Admission
Sepsis APACHE II: a severity of disease classification system Crit Care Med 1985 13(10):818-29 Temp ______
Positive blood culture AND An evaluation of outcome from intensive care in major medical centers Ann Intern Med 1986 104(3):410
Heart rate >⁄= 90 Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II HR ______
and III prognostic systems in a United Kingdom intensive care unit Crit Care Med 1997 25(1):9-15
Temp <⁄= 36 C or >⁄= 38 C
Physiologic Variable 0 1 2 3 4
Resp rate >⁄= 20 OR MAP ______
Temperature 96.8-101.2 101.3-102.1 89.6-93.1 102.2-105.7 >105.7
PCO2 <⁄= 32 on ABG 93.2-96.7
WBC <⁄=4000 OR Heart Rate 70-109 n/a 110-139 140-179 >161 RR ______
>⁄= 12000 OR 55-69 40-54 < 50
>⁄= 10% Bands Oxygenation ______

Without a positive blood culture, the above

findings are consistent with Systemic
MAP

Resp Rate
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(2 x DBP + SBP)/3
70-109

12-24
n/a

25-34
110-129
50-69
6-9
130-159

35-49
>181
<40
>49
Serum Na ______

Inflammatory Response Syndrome 10-11 <6

Serum K ______
(SIRS)
Oxygenation
If FiO2 > 49%, A-a < 200 200-349 350-499 >500 Serum Creatinine ______
Severe Sepsis
The patient must meet the above criteria
AND have hypotension, hypoperfusion or
If FiO2 < 50%, PO2 >70 61-70 55-60 <54 Art pH ______
organ dysfunction.
Hypotension is defined as Serum Na+ 130-139 150-154 155-159 160-179 >179 WBC ______
SBP < 90 120-129 111-119 < 111
MAP <⁄= 70 mmHg Hct ______
Serum K+ 3.5-5.4 5.5-5.9 2.5-2.9 6.0-6.9 >7.1
OR drop of >/= 40 mmHg
3.0-3.4 < 2.5
GCS ______
Septic Shock Serum Creatinine 0.6-1.4 n/a 1.5-1.9 2.0-3.4 >3.4 15 – GCS Score
The patient must meet the above criteria (Double if in ARF) <0.6 (Eye + Motor + Verbal)
AND
have refractory shock (hypotension not
responsive to fluid resuscitation).
Arterial pH
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7.33-7.49 7.50-7.59 7.25-7.32 7.60-7.69
7.15-7.24
>7.69
<7.15 Physiology Score ______
Systolic BP <⁄= 90,or MAP <⁄= 70 WBC 3.0-14.9 15-19.9 20-39.9 n/a >39 Glasgow Coma Score
1.0-2.9 <1.0
Acute Lung Injury Eye response _____
Bilateral infiltrates on radiograph Hematocrit 30-45.9 46-49.9 50-59.9 n/a >59 1 -None
PO2/FiO2 201-300 regardless of PEEP 20-29.9 <20 2 - Eyes open to pain
No evidence of elevated left atrial pressure GCS 3 - Opens to verbal command
OR PCWP < 18 mmHg Score = 4 - Open spontaneously
15 – GCS Score (Eye
Acute Respiratory Distress + Motor + Verbal) Verbal response _____
Syndrome (ARDS) 1 – None
2 – Incomprehensible sounds
PO2/FiO2 <⁄=200 3 – Inappropriate words
Physiology Score ______ 4 – Confused
Sepsis Treatment Goals Total APACHE II Score = Acute Physiology Score + Chronic Health Points + Age Points 5 – Oriented
Institute for Healthcare Improvement
(www.ihi.org)
1. Blood cultures before administration of
broad spectrum antibiotics
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Chronic Health Points for APACHE II
Non-operative, or emergency post-op & any conditions below 5
Motor Response _____
1 – None
CHP Score ______ 2 – Extension to pain
2. Broad spectrum antibiotics given Elective operation & any conditions below 2 3 – Flexion to pain
in </= 1 hr (ICU admit) 4 – Withdrawal from pain
In </-=3 hr (ED admit) Cirrhosis with portal hypertension OR encephalopathy; class IV angina; chronic hypoxia; hypercarbia 5 – Localizes pain
3. CVP of 8-12mmHg in </= 6 hours 6 – Obeys commands
or polycythemia; chronic dialysis; immunocompromised
4. ScvO2 >/= 70% OR SvO2 >/= 65% Total Score < 9 indicates
in </= 6 hours severe brain injury
5. Low dose steroids, if applicable Age Points for APACHE II
LANCET (ii) 81-83, 1974.
6. Drotrecogin Alfa administrations <45 = 0
in </= 24 hours, if applicable 45-54 = 2
7. Glycemic control with median blood 55-64 = 3
glucose of < 150 within 24 hours Predicted Mortality Based on
65-74 = 5
8. Inspiratory plateau pressure of APACHE II Score
< 30cm H2O With a tidal volume of >74 = 6 Age Score ______
Score Interpretation
6 ml/kg (based on Ideal Body
Total APACHE II Score ______ 0-4 ~4% death rate
Weight)

Ventilator Strategies (www.ihi.org)

www.e-medtools.com 5-9
10-14
~8% death rate
~15% death rate
1. Head of bed elevated by >/= 30 degrees Stages of chronic kidney disease 15-19 ~25% death rate
2. Daily sedation vacation AND
Stage GFR (mL/min/1.73m2 ) Action 20-24 ~40% death rate
assessment of ability to wean from
1 >89 Diagnosis and treatment. Treat comorbid conditions. Slow progression. 25-29 ~55% death rate
ventilator
3. Stress ulcer prophylaxis 2 60-89 Estimate progression 30-34 ~75% death rate
4. Deep Venous Thrombosis prophylaxis 3 38-59 Evaluate and treat complications over 34 ~85% death rate
4 15-29 Prepare for kidney replacement therapy
Oxygen Coverage 5 <15 Replacement (if uremia is present)
PO2<⁄=55 OR Sats <⁄=90% The National Kidney Foundation recommends estimating GFR by use of the Cockcroft-Gault or MDRD equations
PO2 56-59 OR Sats 89%
General Acid-Base Rules
WITH
CHF Acidosis Alkalosis
∆pH = -0.008 x ∆PCO2 ∆pH = 0.008 x ∆PCO2
Cor pulmonale
P wave >2mm
lead II, III or AVF
Acute Resp
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∆HCO3 = 0.1 x ∆PCO2 (+/-3) ∆HCO3 = -0.2 x ∆PCO2
(usually not to less than 18 mEq/L)
Hct >56% Chronic Resp PCO2 = 2.4(HCO3) – 22 ∆HCO3 = -0.4 x ∆PCO2
Sats <⁄=88% for >5 minutes ∆HCO3 = 0.35 x ∆PCO2 (+/-4) (usually not to less than 18 mEq/L)
during sleep Metabolic PCO2 = 1.5(HCO3) + 8 +/-2 PCO2 = 0.9(HCO3) + 9 +/-2
NOT COVERED
PCO2 ~ last 2 digits pH ∆PCO2 = 0.6 x ∆HCO3
PO2 >59 OR Sats >89% ∆PCO2 = 1.2 x ∆HCO3

©MB and RR 2006, 2007 Revised 13Nov07 www.e-medtools.com Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures