COPD Patient Evaluation

Date Time ROS
Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych WNL See HPI

Patient Name
Chief Complaint or Reason For Visit HPI

DOB

MRN

Symptom Severity and Frequency

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‰Asymptomatic with usual activity ‰Symptomatic with usual activity ‰Symptomatic with minimal activity ‰Symptomatic at rest ‰Recent antibiotic use ‰Recent oral steroid use ‰Recent ED visits ‰Recent hospital admissions ‰Weight loss/Decreased appetite
Physical Exam ‰Checkedwww.e-medtools.com normal limits box indicates findings are within
General ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro

FEV1
‰At risk ‰Mild ‰Moderate ‰Severe ‰Very Severe >80% >79% 50-79% 30-49% <30%

FEV1 FVC

t 70%
<70% < 70% < 70% < 70%

‰ Alert

Vital signs

Temp

Pulse

BP

RR

Pulse ox at rest

With exercise

History
Allergies PMSH Social Family

No changes See HPI

‰ Nasal mucosa ‰ Dentition ‰ Oropharynx Mallampati ‰I ‰II ‰III ‰IV ‰ Palpation ‰ Thyroid ‰ No JVD www.e-medtools.com ‰ Auscultation ‰ Percussion ‰Respiratory effort ‰Palpation ‰Chest wall ‰ Clear S1 S2 ‰ No murmur ‰ No gallop ‰No rub ‰ Peripheral pulses ‰ No peripheral edema ‰No palpable masses ‰ No hepatosplenomegaly ‰ No hepatojugular reflux Tobacco Use ‰ Lymph nodes ‰Tone ‰ Gait ‰ Digits ‰ No rashes, ecchymoses, nodules, ulcers
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______ # Packs X ______ # Yrs ‰Never smoked ‰Quit ‰Unwilling to quit ‰Willing to consider quitting ‰Quit, but resumed smoking ‰Willing to quit within 1 month

COPD Therapy
Current New Short-acting beta ‰ ‰ agonist Inhaled steroid Long-acting beta agonist Long acting anticholinergic Theophylline Oral steroids Antibiotics Nicotine replacement Buproprion Nicotine receptor blocker CPAP

‰ Orientation www.e-medtools.com ‰Affect

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Impression and Plan

Tests to be ordered

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‰Bronchoscopy ‰Pulmonary Function Testing ‰Methacholine challenge ‰6 Minute Walk Test ‰Sleep study ‰CXR ‰Chest CT ‰without contrast ‰Echocardiogram with ‰Bubble study ‰PA pressures ‰Cardiopulmonary Stress Test ‰Pulmonary Rehabilitation ‰Surgical eval for lung reduction ‰Bone density evaluation ‰Pneumococcal vaccine ‰Influenza vaccine ‰Labs

BiPap Oxygen Therapy

Education and Instruction ‰Smoking cessation ‰Peak flow meter use ‰Inhaler use ‰Importance of vaccinations ‰Risks of alcohol, narcotics and BZD ‰Medication side effects ‰Supplemental oxygen for air travel ‰US ‰CT

Follow up

Signature
CODE STATUS: Data Reviewed

‰ Full code ‰ Do Not Attempt Resuscitation

Care Coordinated With

‰ ER Notes ‰ Old Chart ‰EMS Note ‰ECG ‰Nursing Notes & Vitals log ‰ Labs ‰ X Rays ‰MRI ‰ER MD ‰HCPOA ‰Primary Care MD ‰Case Management ‰Social Worker ‰Pharmacy
©MB and RR 2006, 2007 www.e-medtools.com

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