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Pulmonary Clinic History and Physical

Pulmonary Clinic History and Physical

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Published by e-MedTools
The pulmonary new clinic patient evaluation MedicalTemplate is suitable for pulmonologists and other health care providers.

The pulmonary new clinic patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.

* History
o Chief complaint
o History of present illness
o Past medical and surgical history
o Social history
o Family history
o Review of systems
* Examination
* Medical Decision Making
o Review of data (labs, tests, imaging, old records)
o Assessment and plan
The pulmonary new clinic patient evaluation MedicalTemplate is suitable for pulmonologists and other health care providers.

The pulmonary new clinic patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter.

* History
o Chief complaint
o History of present illness
o Past medical and surgical history
o Social history
o Family history
o Review of systems
* Examination
* Medical Decision Making
o Review of data (labs, tests, imaging, old records)
o Assessment and plan

More info:

Published by: e-MedTools on Sep 08, 2008
Copyright:Traditional Copyright: All rights reserved

Availability:

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07/10/2013

 
OutpatientPulmonary Evaluation
Patient Name DOB MRN
©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature
Review of SystemsChief complaint/Reason for consult
Start Time Stop Time Date
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
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
No
 
 Adrenal
Breast
Colon
Leuk/Lymph
Lung
Melanoma
Renal cell
Skin
Pituitary
Prostate
Testicular 
Thyroid
Treatment 
Surgical Resection
Chemotherapy 
Radiation
ADLs
This patient is able to perform the following independently 
Eating
Bathing
Dressing
Toileting
Transfers
Vaccines
This patient iscurrent on the following 
Seasonal Influenza
H1N1 Influenza
Pertussis
Pneumococcal
Varicella
Tetanus
Surgeries
 
 Appendectomy
Cholecystectomy
Pacemaker 
Organ transplant
 Arterial bypass
Colon resection
Defibrillator 
Coronary Artery Bypass
Hysterectomy
Other 
Cardiac valve repair or replace
Nephrectomy
Hip replacement
Carotid Endarterectomy
Splenectomy
Knee replacement
Social History
Risk factors
 
Denies
Yes
Tobacco use
Number Pack-Years _________ 
Denies
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
Denies
Yes
Recreational drug use
Route
Inhalation
Injection
Ingestion
Denies
Yes
Drug dependence
Type
Narcotics
Benzodiazepines
 
Denies
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
Hot tub or Jacuzzi
High Pressure washings
Pets or feathers
Chemicals or fires

Military HIstoryFamily History
 Asthma
Coronary Artery Disease
Renal Dysfunction
Malignancy
CHF
Pancreatitis
Thrombotic disorder 
Other 
COPD
Peripheral Artery Disease
Thyroid Disease
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OutpatientPulmonary Evaluation
Patient Name DOB MRN
©MB and RR 2006-2010 MedicalTemplates@e-medtools.com Revised 3Feb2010 Health Care Provider Signature
ExamLabs
 \____/ ____ / ____ / ____ // \ \ \ \
Radiology
CXR
CT/Chest
Other 
Constitutional
WNL = Within Normal Limits
Height
 _______ 
in
cm
Weight
 _______ 
lb
kg
Temperature
 _____ 

Respiratory Rate
 _______ 
Pulse
Rate
 _______ AND
Rhythm
Regular 
Irregular 
 Blood Pressure Sitting
 __________ 
OR 
Standing
 __________ 
OR 
Lying
 __________ 
 
Optional 
Sats
 _____ 
%
x
Body habitus
WNL
Cachectic
Obese
x
Grooming
 
WNL
Unkempt
ENT
x
Nasal mucosa, septum, and turbinates
 
WNL
Edema or erythema present
x
Dentition and gums
WNL
Dental caries
Gingivitis
x
Oropharynx
WNL
Edema or erythema present
Oral ulcers
Oral Petechiae
Mallampati
I
II
III
IV
Neck
x
Neck
WNL
Erythema or scarring consistentwith
recent or 
old radiation dermatitis
x
Thyroid
WNL
Thyromegaly
Nodules palpable
Neck mass
x
Jugular Veins
WNL
JVD present
a, v or cannon a waves present
Respiratory
 
x
Chest
Free of defects, expands normally and symmetrically
Erythema consistent with radiation dermatitisScarring consistent with
Old, healed radiation dermatitis
Prior surgery
Trauma
Other 
x
Respiratory effort
WNL
 Accessory muscle use
Intercostal retractions
Paradoxic movements
x
Chest percussion
WNL
Dullness to percussion
Lt
Rt
Hyperresonance
Lt
Rt
x
Tactile fremitus
WNL
Increased 
Decreased 
 
x
Auscultation
WNL
Bronchial breath sounds
Egophony
Rales
Rhonchi
Wheezes
Rub
Cardiovascular 
x
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
x
Peripheral pulses
Palpableand symmetric
 Absent
Weak
x
Peripheral edema
 Absent
Present
Gastrointestinal
x
Abdomen
WNL
Mass present
LUQ
RUQ
LLQ
RLQ
Pulsatile
x
Liver and spleen
Palpable and WNL
Unable to palpate
Liver 
Spleen
Organomegaly 
Liver 
Spleen
Lymphatics
2 areas must be examined)
x
Lymph node exam
WNL Areas examined
Neck
 Axilla
Groin
Other Lymphadenopathy noted
Neck
Submental
 Axillary
Epitrochlear 
Inguinal
Other 
Musculoskeletal
x
Muscle tone
WNL, and no atrophy noted
Increased
Decreased
 Atrophy present
x
Gait and station
WNL
 Ataxia
Wide based gait
Shuffle Patient leans
Rt
Lt
Front
Back
Extremities
x
Exam
WNL
Clubbing
Cyanosis
Petechiae
Synovitis
Rt
Lt
Skin
x
Exam
WNL
Rash
Ecchymosis
Nodules
Ulcer 
Neurologic
x
Orientation
Oriented
NOT
oriented to
Person
Time
Place
x
Affect
 
WNL
 Agitated
 Anxious
Depressed
Additional Findings
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