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COPD Evaluation

Date Time
Yes Constitution Fatigue or Malaise Fever or chills Appetite changes Eyes Vision changes New eye pain ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Hallucinations No

Patient _____________________________________ DOB _____ / _____ / _____ MRN ___________________ Chief complaint/Reason for consult Referring MD

History of Present Illness ‰Patient is Nonverbal. History obtained from ‰Family or Friend ‰Medical records ‰Recent Weight loss or decreased appetite ‰Recent Antibiotic use ‰Recent Oral steroid use ‰Recent ER visits ‰Recent Hospital admissions ‰Planned air travel in near future
Chronic Bronchitis symptoms ‰Increased cough ‰Increased dyspnea ‰Increased sputum production COPD Symptoms

FEV1/FVC FEV1 SEVERITY ‰Spirometry evaluation performed within previous 12 months ‰Asymptomatic with usual activity ‰ 70% >80% At risk ‰Symptomatic with usual activity ‰<70% >79% Mild ‰Symptomatic with minimal activity ‰< 70% 50-79% Moderate ‰Symptomatic at rest www.e-medtools.com Severe ‰<70% 30-49% ‰<70% <30% Very Severe Allergies ‰Allergy List reviewed ‰No food or drug allergies Medications ‰Medications reviewed ‰Medications reconciled with Nursing Home or Hospital discharge Information

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Past Medical, Family Social History ‰Anemia ‰Hypersensitivity pneumonitis www.e-medtools.com ‰Asthma ‰Hypertension ‰Adrenal dysfunction ‰Inflammatory Bowel Disease ‰Arthritis ‰RA ‰Myocardial Infarction ‰Blood clots ‰DVT ‰PE ‰Neuromuscular weakness ‰Cerebral Artery Disease ‰Osteoporosis ‰CHF ‰Pancreatitis ‰Churg Strauss ‰Peripheral Artery www.e-medtools.comDisease ‰COPD ‰Pituitary infarct or hemorrhage ‰Coronary Artery Disease ‰Protein deficiency ‰C ‰S ‰Cystic Fibrosis ‰Renal dysfunction ‰ESRD ‰Diabetes ‰1 ‰2 Dialysis ‰Hemo ‰Peritoneal ‰DIC ‰Sarcoidosis ‰Endocarditis ‰Seizure disorder www.e-medtools.com ‰GERD ‰Gout ‰Sleep Apnea ‰CPAP ‰BiPAP ‰Hepatic dysfunction ‰Systemic Lupus Erythematosis ‰Histiocytosis ‰Strokes ‰HIV/AIDS ‰Thrombocytopenia ‰ITP ‰TTP
Malignancy

‰Thyroid disease ‰hypo ‰hyper ‰PPD Result ‰Positive ‰Negative ‰Tuberculosis Treatment

Date

‰Steroid use, chronic ‰Immunosuppressive therapy ‰Chemotherapy ‰Radiation exposure ‰Organ failure or transplant ‰ECHO/Stress test ‰PFTs ‰Pap Smear ‰Mammogram ‰Colonoscopy ‰Sleep study

‰Adrenal ‰Colon ‰Leukemia/Lymphoma ‰Melanoma ‰Renal cell ‰Thyroid ‰Breast ‰Lung ‰Pituitary ‰Prostate ‰Testicular Stage Treatment ‰Surgical Resection ‰Radioablation ‰Chemotherapy Last Tx ‰Radiation Last Tx
Surgeries ‰CABG ‰Splenectomy ‰Lung resection ‰Pleurodesis ‰Organ transplant Social History / Risk factors

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‰Other

‰No ‰Yes ‰No ‰Yes ‰No ‰Yes

Ever smoker ___ # Packs X ____ # Yrs Chews tobacco Quit tobacco use Quit date _________ ‰Patient is unwilling to quit ‰Patient willing to consider quitting ‰Patient quit, but resumed smoking ‰Patient willing to quit within 1 month ‰No ‰Yes Patient has tried smoking cessation aids

Recreational drug use

‰No ‰Yes

Usual route

‰Inhalation ‰Injection ‰Ingestion

Drug dependence Alcohol use

‰No ‰Yes ‰Narcotics ‰Benzodiazepines ‰No ‰Yes ___
Drinks per ‰Day ‰Week

‰Nicotine replacement ‰Buproprion or nortriptyline ‰Nicotine receptor blockade

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 ‰Aerosolized water Source ‰Hot tub ‰Whirlpool baths ‰High Pressure washings ‰Other ‰Pets or feathers ‰Chemicals or fires ‰Military Experience Family Medical History

‰Asthma ‰CHF ‰COPD ‰Coronary Artery Disease ‰Malignancy ‰Pancreatitis ‰Thrombotic disorder

©MB and RR 2006-2010

Revised 31Dec09

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Health Care Provider Signature

COPD Evaluation

Patient _____________________________________ DOB _____ / _____ / _____ MRN ___________________
General Multisystem requires performing ALL of 9 organ systems, AND 2 elements documented in each organ system

Exam To qualify as a comprehensive exam:

Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND

1 element in every other organ system is expected

Labs \____/ / \ ____ / ____ / ____ / \ \ \

Constitutional (Must include • 3 vitals) WNL = Within Normal Limits Height ___________ ‰in ‰cm Weight ___________ ‰lb Temperature __________ Pulse Rate __________

‰kg ‰Irregular

AND Rhythm ‰Regular

Blood Pressure sitting __________ / __________ OR standing __________ / __________ Blood Pressure lying
Body habitus ‰WNL

__________ / __________
Optional Sats _____ % Cardiac Output _____ SVR _____

ENT

‰Cachectic ‰Obese www.e-medtools.com Grooming ‰WNL ‰Unkempt
Nasal mucosa, septum, and turbinates Dentition and gums ‰WNL ‰Dental caries

Respiratory Rate__________

Pulmonary Function Tests Neck

‰WNL ‰Edema or erythema present ‰Gingivitis www.e-medtools.com Oropharynx ‰ WNL ‰Edema or erythema present ‰Oral ulcers ‰Oral Petechiae Mallampati ‰I ‰II ‰III ‰IV
Thyroid ‰ WNL ‰Thyromegaly

Neck

Respiratory

‰ WNL ‰Erythema or scarring consistent with ‰recent or ‰old radiation dermatitis ‰Nodules palpable ‰Neck mass _____________________ www.e-medtools.com Jugular Veins ‰ WNL ‰JVD present ‰a, v or cannon a waves present
Scarring consistent with

Polysomnography

Cardiovascular

‰Free of defects, expands normally and symmetrically ‰Erythema consistent with radiation dermatitis ‰Old, healed radiation dermatitis ‰Prior surgery ‰Trauma ‰Other Respiratory effort ‰WNL ‰Accessory muscle use ‰Intercostal retractions ‰Paradoxic movements www.e-medtools.com Chest percussion ‰WNL ‰Dullness to percussion ‰Lt ‰Rt ‰Hyperresonance ‰Lt ‰Rt Tactile fremitus ‰WNL ‰ Increased ‰ Decreased __________________________________ Auscultation ‰WNL ‰Bronchial breath sounds ‰Egophony ‰Rales ‰Rhonchi ‰Wheezes ‰Rub present
Chest Heart sounds

Radiology

‰CXR ‰CT/Chest ‰Other

Gastrointestinal

‰Clear S1 S2 ‰No murmur, rub or gallop ‰Gallop audible ‰Rub audible www.e-medtools.com ‰Murmur present ‰Systolic ‰Diastolic Grade ‰I ‰II ‰III ‰IV ‰V ‰VI Peripheral pulses ‰Palpable and symmetric ‰Absent ‰Weak Peripheral edema ‰Absent ‰Present
Abdomen

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Liver and spleen ‰Palpable and WNL Lymphatics (•2 areas must be examined) Lymphadenopathy noted ‰Neck

‰WNL ‰Mass present ‰LUQ ‰RUQ ‰LLQ ‰RLQ ______________ ‰Pulsatile Unable to palpate ‰Liver ‰Spleen Organomegaly ‰Liver ‰Spleen ‰Neck ‰Axilla ‰Groin ‰Other ___________________ ‰Submental ‰Axillary ‰Epitrochlear ‰Inguinal ‰Other ___________

Lymph node exam ‰WNL Areas examined

Musculoskeletal

Muscle tone ‰WNL, and no atrophy noted Gait and station ‰WNL

Extremities Skin

‰Increased ‰Decreased ‰Atrophy present ‰Ataxia ‰Wide based gait ‰Shuffle Patient leans ‰Rt ‰Lt ‰Front ‰Back ‰Cyanosis ‰Petechiae ‰Synovitis ‰Rt ‰Lt
________________________

Exam ‰WNL ‰Clubbing Exam ‰ WNL ‰Rash Orientation ‰Oriented

Neurologic

‰Ecchymosis ‰Nodules ‰Ulcer
NOT oriented to ‰Person ‰Time ‰Place

Affect ‰WNL Additional Findings

‰Agitated ‰Anxious ‰Depressed

©MB and RR 2006-2010

Revised 31Dec09

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Health Care Provider Signature

COPD Evaluation
Plan

Patient _____________________________________ DOB _____ / _____ / _____ MRN ___________________ Impression

COPD Therapy

‰PRN albuterol “rescue agent” œ52 ‰Inhaled corticosteroids ‰Long-acting beta agonist œ52 ‰Theophylline ‰Long-acting anti-cholinergic œ52 ‰Oral steroids ‰Antibiotics for exacerbations ‰Smoking cessation aids ‰Long term oxygen therapy

‰ I have personally discussed Code Status with this patient
and the consequences of their Code Status decision. Code Status

and I believe that this patient understands their medical condition

‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary

‰ This patient has an advanced health care directive, and has named _______________________________ as their HCPOA.

If no history of glaucoma or urinary retention

‰Patient advised to quit smoking ‰Patient advised of risks of alcohol, ‰Medication Side Effects discussed
Schedule Patient For
narcotic and benzodiazepine use

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‰Bronchoscopy ‰Pulmonary Function Testing ‰Methacholine Challenge ‰6 Minute Walk Test ‰Bone density evaluation ‰CXR ‰Chest CT ‰with contrast ‰ECHO ‰with bubble study ‰assess PA pressures ‰Cardiopulmonary Stress Test ‰Sleep Study ‰CT Surgery eval for lung reduction ‰Pneumococcal vaccine ‰Influenza vaccine ‰Pulmonary Rehabilitation
Labs

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‰CBC ‰BMP ‰CMP ‰LFTs ‰Hepatitis panel ‰HIV ‰Alpha 1 antitrypsin

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Signature cc

©MB and RR 2006-2010

Revised 31Dec09

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Health Care Provider Signature