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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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