COPD Evaluation

Date
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 Claudication symptoms 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

Patient Chief complaint/Reason for consult
No

DOB

MRN Referring MD

Time
Yes

History of Present Illness

‰Patient is Nonverbal.

History obtained from

‰Family ‰Medical records

©MB and RR 2006-2009

e-

Revised 16Sep09

SA m ed M PL to ol E s. co m
‰Recent Antibiotic use ‰Recent ER visits ‰Recent Weight loss or decreased appetite cent lo los ‰Recent Oral steroid use ‰Recent Hospital admissions ‰Planned air travel in near future al admis ed tra ‰Spirometry evaluation performed within previous 12 months thin in
COPD Symptoms ‰Asymptomatic with usual activity ity ty FEV1/FVC ‰ 70% 0% FEV1 >80% 0% SEVERITY SE SEV At risk

‰Symptomatic with usual activity tivity ‰Symptomatic with minimal activity mal activ al ‰Symptomatic at rest
Medications

‰<70% ‰< 70% 7 ‰<70% <70 ‰<70% 70%

Chronic Bronchitis symptoms sym ‰Increased cough co

>79% 50-79% 50 30-49% <30%

Mild Moderate Severe Very Severe ry S

‰Increased dys dy dyspnea ‰Increased sputum production ncreased

‰Medications reviewed eviewed ‰Allergy List reviewed Aller ‰Medications reconciled with Nursing Home or Hospital discharge Information œ46 ‰No food or drug allergies nciled tion œ 6 N Past Medical, Family S Social History ‰Asthma ma ‰Adrenall dysfunction dysfunct ‰Arthritis ‰RA A RA ‰Blood clots ‰DVT ‰PE ‰CHF ‰COPD ‰Coronary Artery Disease ronary ‰Cystic Fibrosis ‰Diabetes ‰1 ‰2 Dia ‰Endocarditis ‰GERD ‰Gout ‰Hemolytic anemia lytic ‰Hepatic dysfunction patic sfunction ‰HIV/AIDS S ‰Hypertension Hypertension e
Malignancy ignancy

Allerg Allergies

‰Inflammatory Bowel Disease mmatory Dise ‰Neuromuscular weakness uromuscular cular ‰Osteoporosis rosi ‰Organ transplant trans t ‰Pancreatitis ‰Peripheral Artery Disease Peripheral Dise Dis ‰Pituitary infarct or hemorrhage o ‰Protein deficie deficiency ‰C ‰S ‰Renal dysfunction ‰ESRD nal dysfu dy ‰Hemodialysis ‰Peritoneal dialysis Hemodi emod ‰Sarcoidosis Sarc ‰Seizure disorder S ‰Sleep Apnea ‰CPAP ‰BiPAP ‰Systemic Lupus Erythematosis ‰Thrombocytopenia ‰ITP ‰TTP ‰Thyroid disease ‰hypo ‰hyper

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

Notes

‰Tuberculosis ‰PPD Result ‰Positive ‰Negative ‰Tuberculosis Treatment

Date

‰Adrenal ‰Colon ‰Leukemia/Lymphoma ‰Melanoma ‰Renal cell ‰Thyroid ‰Breast ‰Lung ‰Pituitary ‰Prostate ‰Testicular renal on L Stage ge Treat Treatment ‰Surgical Resection ‰Radioablation ‰Chemotherapy Last Tx T ‰Radiation Last Tx
Surg Surgeries ‰CABG ‰Splenectomy ‰Organ transplant So Social History / Risk factors

‰Lung resection ‰Pleurodesis ‰Other

‰Denies ‰Yes D Deni ‰Denies ‰Yes D ‰Denies ‰Yes

Ever smoker ___ # Packs X ____ # Yrs Recreational drug use ‰Denies ‰Yes ‰Inhalation ‰Injection ‰Ingestion Chews tobacco Drug dependence ‰Denies ‰Yes ‰Narcotics ‰Benzodiazepines Quit tobacco use Quit date _________ Alcohol use ‰Denies ‰Yes ___ Drinks per ‰Day ‰Week Willingness to Quit ‰Unwilling ‰Considering ‰Quit but resumed ‰Within 1 month Patient has tried smoking cessation aids ‰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 ‰Military Experience ‰Chemicals or fires Family Medical History

‰Asthma ‰CHF ‰COPD ‰Coronary Artery Disease ‰Malignancy ‰Pancreatitis ‰Thrombotic disorder e-medtools.com Health Care Provider Signature

COPD Evaluation

Patient

DOB
General Multisystem requires performing ALL of 9 organ systems, AND

MRN
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

Ventilator

Mode ‰AC‰SIMV ‰PC ‰PRVC
Intubation date ____ / ____ / ____ ETT size _____ PS Rate ______ Tidal Vol Plateau ______ ______

Constitutional (

3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam

Height ___________

PEEP ______ FiO2 ______

PO2/FiO2 ______

NonInvasive Ventilator

‰CPAP ‰BiPAP IE ____
IV Medications

‰ Antiarrhythmics ‰ Antihypertensives ‰ Diuretics ‰ Drotrecogin alfa ‰ Heparin ‰ Insulin ‰ Antibiotics
Lines & Monitors

‰ Narcotics ‰ Pressors ‰ Sedation ‰ Steroids ‰ Thrombolytic ‰ TPN

‰Telemetry ‰Chest tube

Left Air leak

‰Trach present Size ‰Endotracheal tube Size ‰NG/ND tube ‰PEG/PEJ tube ‰Foley catheter ‰Ostomy ‰Central line/PICC
Site

Right Air leak ‰present ‰absent

‰present ‰absent

‰Peripheral venous access ‰Port access
Labs \____/ / \ Radiology
Site ‰No sign of infection

‰No sign of infection

‰No sign of infection

____ / ____ / ____ / \ \ \

‰CXR ‰CT/Chest ‰Other

©MB and RR 2006-2009

e- S m A ed M PL to ol E s. co m
______

ENT

‰Body habitus wnl ‰Cachectic ‰Obese bese ese ‰Grooming wnl ‰Unkempt
Nasal mucosa, septum, and turbinates rbinates

Temperature __________ Pulse Rate __________ AND Rhythm ‰Regular ‰Irregular egul Blood Pressure sitting _____ / _____ OR standing _____ / _____ OR lying _____ ng __ ___ / _____ Respiratory Rate__________ Optional Sats _____ % Cardiac Output _____ SVR _ onal Sa nal S _____

‰in ‰cm

Weight ___________ ‰lb

‰kg

WNL = Within Normal Limits

L D Dentition and gums ‰WNL ‰Dental caries

EE ____

Neck

‰ WNL ‰Edema or erythema presentt Edem ‰Gingivitis Ging Oropharynx ‰ WNL ‰Edema or erythema pres pre present ‰Oral ulcers ‰Oral Petechiae cers II V Mallampati ‰I ‰II ‰III ‰IV
Thyroid ‰ WNL ‰Thyromegaly yrome

WNL = Within Normal Limits imits

Neck

Resp

‰ WNL ‰Erythema or scarring consistent with ‰recent or ‰old radiatio dermatitis NL h radiation ‰Nodules palpable ‰Neck mass _____________________ lpable _ ____ present ‰a, v or cannon a waves presen present Jugular Veins ‰ WNL ‰JVD p ula ular

WNL = Within Normal Limits L

CV

‰Chest is free of defects expands normally and symmetrically ‰Erythema consistent with radiation dermatitis hest de defects, rmally nd ‰Scarring consis with old, healed radiation dermatitis ‰Surgical scar present ‰Scar, other carring consi consistent W WN ory Intercosta erco Resp effort ‰WNL ‰Accessory muscle use ‰Intercostal retractions ‰Paradoxic movements ness to Chest percuss percus percussion ‰WNL ‰Dullness to percussion ‰Lt ‰Rt ‰Hyperresonance ‰Lt ‰Rt Ta Tactile fremitus ‰WNL ‰ Increased ‰ Decreased __________________________________ fre rea De Decreas L soun sound Aus Auscu Auscultation ‰WNL ‰Bronchial breath sounds ‰Egophony ‰Rales ‰Rhonchi ‰Wheezes ‰Rub present ‰Clear S1 S2 ‰No murmur, rub or ga ‰Gallop audible ‰Rub audible gallop ‰Murmur present ‰Systolic ‰Diastolic Grade ‰I ‰II ‰III ‰IV ‰V ‰VI ur nt ystolic ‰Peripheral pulses palpable ‰No peripheral edema Peripheral pulses ‰Absent ‰Weak eripheral al
Abdomen n

W WNL = Within Normal Limits mits

GI

WNL = Within Normal Limits

Lymph (•2 areas must be examined) •2 ex

‰WNL Mass present ‰LUQ ‰RUQ ‰LLQ ‰RLQ ______________ ‰Pulsatile ‰Liver and spleen pa p palpation WNL Unable to palpate ‰Liver ‰Spleen Enlarged ‰Liver ‰Spleen
WNL = Within Normal Limits

‰Lymph nod exam WNL node

Areas examined

Lymphadenopathy noted in Lymp Lympha

Musc c

‰Neck ‰Axilla ‰Groin ‰Other ___________________ ‰Neck ‰Axilla ‰Groin ‰Other ___________________

WNL = Within Normal Limits With

Ex Extrem WNL = Within Normal Limits Sk Skin
WNL = Within Normal Limits

‰Muscle tone WNL, and no atrophy noted Tone is ‰Increased ‰Decreased ‰Atrophy present M ‰Gait and station WNL ‰Ataxia ‰Wide based gait ‰Shuffle Patient leans ‰Rt ‰Lt ‰Front ‰Back ‰Exam wnl ‰Clubbing ‰Cyanosis ‰Petechiae ‰Synovitis ‰Rt ‰Lt
________________________

Neuro

‰No rashes, ecchymoses, nodules, ulcers ‰Rash ‰Bullae ‰Pressure Ulcer Stage ‰1 ‰2 ‰3 ‰4 ‰Oriented ‰Affect is WNL
NOT oriented to ‰Person ‰Time ‰Place
OR Patient appears

WNL = Within Normal Limits

‰Agitated ‰Anxious ‰Depressed
APACHE II Score __________

Additional Findings

Glasgow Coma Score E _____ V _____ M _____

Revised 16Sep09

e-medtools.com

Health Care Provider Signature

COPD Evaluation
Recommendations

Patient Impression

DOB

MRN

‰Aggressive pulmonary toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Daily sedation vacation and ‰Head of bed elevated > 30 Degrees ‰Intense glycemic control 100-150 ‰Central line change or removal
(send tip for culture) neurologic assessment

‰ I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
decision maker) understands their medical condition and the consequences of their Code Status decision. Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary s. T ‰ This patient has advanced health care directives. Their HCPOA is

‰Physical therapy ‰Enteral/Parenteral feeds ‰Supplemental IV Fluids ‰Smoking cessation aids ‰Pneumonia vaccine prior to discharge ‰Influenza vaccine prior to discharge
Antiviral ‰Treatment ‰Prophylaxis

‰Oseltamivir ‰Zanamivir ‰Amantadine ‰Ramantadine ‰Antibiotics
Diagnostics

Metabolic Panel ‰Basic ‰Complete

‰CBC with differential ‰PT, PTT, INR ‰HIV ‰Hepatitis panel ‰BNP ‰Cardiac Enzymes

‰12-lead EKG ‰Echocardiogram ‰Chest x-ray ‰PA and Lateral ‰Decubitus ‰CT of chest ‰Other

©MB and RR 2006-2009

eSignature cc Revised 16Sep09 e-medtools.com Health Care Provider Signature

‰Nasal or nasopharyngeal swab ‰Nasal wash or aspirate ‰Cultures ‰Sputum ‰Blood ‰Urine ‰CSF ‰Bacterial ‰Fungal ‰AFB ‰PPD Testing ‰Quantiferon for TB ‰Urinary Antigen ‰Histoplasma ‰Legionella ‰Serum mycoplasma

SA m ed M PL to ol E s. co m

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