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Pneumonia Evaluation Patient Name DOB MRN Date

Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Review of Systems Yes No
Fatigue or Malaise  

Fever or chills  

History of Present Illness ‰Patient is Nonverbal. History obtained from ‰Family ‰Medical records
Appetite changes  
Conjunctivitis  ✔
New eye pain ✔

Blurred vision ✔

Sore throat ✔ 
Swollen uvula ✔ 
Jaw pain ✔ 

Dyspnea ✔ 
Cough ✔ 
Phlegm ✔ 
Hemoptysis ✔ ‰History of recent travel
Wheeze ✔ ‰History of chemotherapy, use of immunosuppressive drugs, or immunosuppressive disease
Pleuritic Symptoms
Chest pain
Ankle edema
Nausea or vomiting

Allergies and Medications
‰Allergy List reviewed ‰No drug allergies ‰No food allergies

‰Medications reviewed ‰Medications reconciled with Nursing Home data

Past Medical, Family Social History (PFSH)

Past Medical History
‰Asthma ‰Diabetes ‰Obstructive Sleep Apnea ‰Other
Weight changes ✔ ‰COPD ‰Hepatic Dysfunction ‰Seizure Disorder
Diarrhea ✔
‰Congestive Heart Failure(CHF) ‰HIV/AIDS ‰Thyroid disease ‰Hyper ‰Hypo
Abdominal pain ✔ ‰Coronary Artery Disease ‰Hypertension ‰Tuberculosis
Hematuria ✔
Malignancy ‰Yes ‰No
Dysuria ✔
‰Adrenal ‰Breast ‰Colon ‰Leuk/Lymph ‰Lung ‰Melanoma ‰Renal cell ‰Skin ‰Pituitary ‰Prostate ‰Testicular ‰Thyroid
Urethral discharge
Treatment ‰Surgical Resection ‰Radioablation ‰Chemotherapy ‰Radiation
Myalgias ✔
ADLs This patient is able to perform the following independently ‰Eating ‰Bathing ‰Dressing ‰Toileting ‰Transfers
Arthralgias ✔
Vaccines This patient is current on the following ‰Seasonal Influenza ‰Pneumococcal ‰Varicella ‰Pertussis ‰Tetanus

Joint swelling ✔
Recent trauma
Surgeries ‰CABG ‰Cardiac valve replacement ‰Splenectomy ‰Organ transplant ‰ Joint replacement ‰Other
New skin lesions Social History Risk factors
Rash ‰No ■
‰Yes Tobacco use Number Pack-Years _________

‰No ‰
■ Yes Quit tobacco use Quit date _________
Willingness to Quit ‰Unwilling ‰Considering ‰Quit but resumed ‰Within 1 month
Headaches ✔
Patient has tried smoking cessation aids Nicotine ‰Replacement ‰Receptor blockade ‰Buproprion or nortriptyline
Seizures ✔
Numbness ✔ ■
‰No ‰Yes Recreational drug use Route ‰Inhalation ‰Injection ‰Ingestion
Paresthesias ■
‰No ‰Yes Drug dependence Type ‰Narcotics ‰Benzodiazepines
Hair loss ✔ ‰No ■
‰Yes Alcohol use ___ Drinks per ‰Day ‰Week
Polydipsia ✔
Occupational and Exposure History
Tremors ✔ ‰Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Neck pain ✔ ‰Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Heme/Lymph ‰Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Bleeding gums ✔ ‰Aerosolized water Source ‰Hot tub ‰Whirlpool baths ‰High Pressure washings ‰Other
Unusual bruising ✔ ‰Pets or feathers
Swollen lymph nodes ‰Chemicals or fires
Allergy/Immunology ‰Military Experience
Nasal congestion ✔ Family History
Rhinorrhea ✔ ‰Asthma ‰Coronary Artery Disease ‰Renal Dysfunction ‰Malignancy
Agitation ✔ ‰CHF ‰Pancreatitis ‰Thrombotic disorder ‰Other
Hallucinations ✔
‰COPD ‰Peripheral Artery Disease ‰Thyroid Disease

©MB and RR 2006-2011 Revised 23Feb2011 Health Care Provider Signature
Pneumonia Evaluation Patient Name DOB MRN Date
Exam WNL = Within Normal Limits

Vitals Constitutional
Height _______ ‰in ‰cm Body habitus ‰WNL ‰Cachectic ‰Obese
Grooming ‰WNL ‰Unkempt 
Weight _______ ‰lb ‰kg ENT
‰WNL ‰Edema or erythema present
Nasal mucosa, septum, and turbinates
Temperature _______ ‰C ‰F Dentition and gums ‰WNL ‰Dental caries
Oropharynx ‰ WNL ‰Edema or erythema present ‰Oral ulcers ‰Oral Petechiae
Pulse Rate _______
Rhythm ‰Regular ‰Irregular Mallampati ‰I ‰II ‰III ‰IV
Blood Pressure ____________ Neck ‰ WNL ‰Erythema or scarring consistent with ‰recent or ‰old radiation dermatitis
‰Sitting ‰Standing ‰Lying Thyroid ‰ WNL ‰Thyromegaly ‰Nodules palpable ‰Neck mass

Jugular Veins ‰ WNL ‰JVD present ‰a, v or cannon a waves present
Oxygen Saturation (Pulse oximetry) Respiratory
Chest ‰Free of defects, expands normally and symmetrically ‰Erythema consistent with radiation dermatitis
_______ ‰Rest ‰Exercise
Scarring consistent with‰Old, healed radiation dermatitis ‰Prior surgery ‰Trauma ‰Other
‰Rest ‰Exercise Respiratory effort ‰WNL ‰Accessory muscle use ‰Intercostal retractions ‰Paradoxic movements

NonInvasive Ventilator
‰CPAP ‰BiPAP Ins ____
Exp ____

Date of Intubation ________________


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

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
Peripheral pulses ‰Palpable and symmetric ‰Absent ‰Weak
Peripheral edema ‰Absent ‰Present
‰Endotracheal Tube Size _____ Gastrointestinal
‰Tracheostomy Tube Size _____
Abdomen ‰WNL ‰Mass present ‰LUQ ‰RUQ ‰LLQ ‰RLQ ‰Pulsatile
Rate ____ Tidal Vol ____ FiO2 ____ Liver and spleen ‰Palpable and WNL Unable to palpate ‰Liver
‰Spleen Organomegaly ‰Liver ‰Spleen
Lymphatics (•2 areas must be examined)
Lymph node exam ‰WNL Areas examined ‰Neck ‰Axilla ‰Groin ‰Other
PEEP level ______
Pressure Support level ______
Lymphadenopathy noted ‰Neck ‰Submental ‰Axillary ‰Epitrochlear ‰Inguinal ‰Other
Peak Inspiratory Pressure ______ Musculoskeletal
Plateau Pressure ______
Muscle tone ‰WNL, and no atrophy noted ‰Increased ‰Decreased ‰Atrophy present

ARDS ALI Gait and station ‰WNL ‰Ataxia ‰Wide based gait ‰Shuffle Patient leans ‰Rt ‰Lt ‰Front ‰Back
PO2/FiO2 ‰<200 ‰201-300 ‰>300 Extremities
Exam ‰WNL ‰Clubbing ‰Cyanosis ‰Petechiae ‰Synovitis ‰Rt ‰Lt
\____/ ____ / ____ / ____ / Exam ‰ WNL ‰Rash ‰Ecchymosis ‰Nodules ‰Ulcer
/ \ \ \ \ Neurologic
‰Oriented NOT oriented to ‰Person ‰Time ‰Place
‰Affect is within normal limits OR Patient appears ‰Agitated ‰Anxious ‰Depressed
Additional Findings

‰CXR ‰CT/Chest ‰Other

©MB and RR 2006-2011 Revised 23Feb2011 Health Care Provider Signature
Pneumonia Evaluation Patient Name DOB MRN Date
Medical Decision Making Impression and Plan
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
‰ER Notes decision maker) understands their medical condition, their prognosis and the consequences of their Code
Status decision.
‰Old medical records
Code Status ‰Patient is a FULL CODE ‰DO NOT ATTEMPT Cardiac Resuscitation ‰DO NOT Intubate
‰Previous radiographic imaging data
‰ECHO ‰ This patient has advanced health care directives. Their HCPOA is
‰Pulmonary Function Test
Care Coordinated with
‰HCPOA / Surrogate
‰Other physician or Consultant

Recommended Diagnostics
‰CBC with differential
‰Metabolic Panel ‰Basic ‰Complete

‰Urine for Histoplasma and Legionella
‰Serum mycoplasma

‰Culture, Sputum
‰ Culture, Blood

‰Chest CT (Computed Tomography)
Pneumonia Severity Index
Male Age (in years) 0
Female Age (in years) - 10 0
NH resident Age (in years) +10 0

Comorbid illnesses
Neoplastic disease 0
Liver disease 0
CHF 0 Signature ‰Physician ‰Resident ‰C-FNP ‰PA-C
Cerebrovascular disease 0
Renal disease 0

Physical exam findings

Altered mental status
Respiratory rate >/= 30 0
Systolic BP < 90 0
Temp < 35 degrees or > 40 0
Pulse > 124 0

Lab Findings
pH <7.35 0
BUN >10.7 mmol/L 0
Sodium <130 mEq/L 0
Glucose > 13.9 mmol/L 0
Hematocrit <30 percent 0
pO2 <60 mmHg 0
Pleural effusion 0

Risk Class Total 0

‰Low I Algorithm ‰I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the Resident,
NP or PA above and I agree with the assessment and plan as outlined.
‰Low II < 71 points
‰Low III 71-90 points Supervising Physician Signature
‰Moderate IV 91-130 points cc
‰High V >130 points

©MB and RR 2006-2011 Revised 23Feb2011 Health Care Provider Signature