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Pulmonary Arterial Hypertension Evaluation
©MB and RR 2006, 2007 Revised 26Sep07
Date Chief complaint/Reason for consult MRNStart timeStop timeAllergies History of present illness
Allergy list reviewed
No drug allergies
No food allergies
Medications
Medication list reviewed
Med list reconciled withNursing Home, Skilled Nursing facility or Rehab facility med list
46
Fatigue, weakness
Cough
Pain
Decreased appetite
Hemoptysis
Weight loss
Calcinosis
Raynaud’s
Esophageal dysfunction
Sclerodactyly
Telangiectasias
Dyspnea
Asymptomatic with usual activity
Symptomatic with usual activity
Symptomatic with minimal activity
Symptomatic at rest
Social HistoryReview of Systems
Tobacco use ____ Packs x ____ Yrs
Quit
Chronic exposure to second hand smoke
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
Inhalational
Injectable
Ingestible
Drug dependence
Narcotics
Benzodiazepines
See HPI WNL
Constitutional
Fatigue, malaise, change in appetite
Eyes
Vision changes, new pain, scotomas
ENT/mouth
Nose bleeds, dental Caries, dental abscesses, jaw pain
Resp
Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness
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 or redness
Skin/breasts
Rashes, new masses or skin lesions, increased sensitivity to sun exposure
Neuro
Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor
Endo
Hair loss, polydipsia, polyuria, gynecomastia
Heme/lymph
Bleeding gums, unusual bruising, swollen lymph nodes
Allergy/Immun
Sinus probs, recurrent infections, anaphylaxis
Psych
Mood changes, agitation, psychosis, delirium, dementia
Occupational History
Family Medical History Past Medical and Surgical History
AV Malformations
Pulmonary Hypertension
Rheumatoid Arthritis
Scleroderma
Systemic Lupus Erythematosus
Malignancy
Breast
Colon
Lung
Melanoma
Prostate
Renal cell
Testicular
Thyroid
Other
Asthma
Appetite Suppressant Use
Neuromuscular weakness
Bronchiectasis
AV Malformations
Occupational exposures
Cryptogenic Organizing Pneumonia
(BOOP)
Cerebral Artery Disease
Peripheral Artery Disease
COPD
Congenital Heart Defects
Scleroderma
Cystic Fibrosis
Left to Right Shunt
Seizure Disorder
Histiocytosis
Atrial Septal Defect
Sjogren
Obstructive Sleep Apnea
Ventricular Septal Defect
Systemic Lupus Erythematosus
CPAP
BiPAP
Patent Ductus Arteriosus
Renal Dysfunction
Tuberculosis
Congestive Heart Failure
Rheumatoid Arthritis
Pulmonary Arterial Hypertension
Coronary Artery Disease
Thrombotic Disease
Pulmonary fibrosis
Dermatomyositis/Polymyositis
Thyroid Disease
Pulmonary Thromboembolic Disease
Diabetes
Malignancy
Pulmonary Venoocclusive Disease
Diastolic Dysfunction
Breast
Sarcoidosis
Nocturnal GERD
Colon
Tuberculosis
Hepatic Dysfunction
Lung
Surgeries
HIV/AIDS
Melanoma
Hypertension
Prostate
Inflammatory Bowel Disease
Renal cell
Mitral Stenosis or Regurgitation
Testicular
Mixed Connective Tissue Disorder
Thyroid
Myocarditis/Pericarditis
Other
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