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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
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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