Chronic Obstructive Pulmonary Disease Evaluation

COPD Evaluation Patient DOB MRN
Date Time Chief complaint/Reason for consult Referring MD

Yes No
Constitution
Fatigue or Malaise History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Fever or chills
Appetite changes
Eyes
Vision changes
New eye pain
ENT/mouth
Nose bleed
m
Dental caries
ol E
Dental abscesses
Jaw pain Recent Antibiotic use Recent ER visits Recent
cent Weight loss
lo
los or decreased appetite
Respiratory Recent Oral steroid use Recent Hospital
al admissions
admis Planned
ed air travel
tra in near future
co
Dyspnea Spirometry evaluation performed within
thin
in previous 12 months
Cough
Phlegm
Hemoptysis
Wheeze
Cardiovascular
to L P COPD Symptoms
Asymptomatic with usual activity
Symptomatic with minimal

< 70%
Symptomatic at rest
mal
7
<70%
<70
ity
ty
Symptomatic with usual activity
<70% tivity
al activity
activ
FEV1/FVC
70%
0%
FEV1
>80%
0%
>79%
50-79%
50
30-49%
SEVERITY
SEV
SE
At risk
Mild
Moderate
Severe
Chronic Bronchitis symptoms
Increased cough
co
Increased dy
Increased
dys
dyspnea
sym
ncreased sputum production
Chest pain
s.
<70%

70% <30% Very
ry Severe
S
Diaphoresis
Medications Allerg
Allergies
ed M
Ankle edema
Medications reviewed
eviewed Aller
Allergy List reviewed
Syncope Medications reconciled 6 N
tion 46
nciled with Nursing Home or Hospital discharge Information No food or drug allergies
Palpitations
Gastrointestinal Past Medical, Family S
Social History
Nausea or vomiting
Asthma
ma Inflammatory
mmatory Bowel Disease
Dise Chemotherapy Notes
m A
Weight changes Adrenall dysfunction

dysfunct Neuromuscular
uromuscular
cular weakness Colonoscopy
Constipation or Diarrhea Arthritis
A RA RA Osteoporosis
rosi ECHO/Stress test
Abdominal pain Blood clots DVT PE Organ transplant
trans t Immunosuppressive therapy
Genitourinary CHF Pancreatitis Mammogram
COPD Per Organ failure
S
Hematuria Peripheral
ipheral Artery Disease
Dise
Dis
Dysuria Coronary
ronary Artery Disease Pituitary infarct oor hemorrhagePFTs
Urethral discharge Cystic Fibrosis Protein deficie
deficiency C S Pap Smear
Musculoskeletal Dia
Diabetes 1 2
Renal
nal dysfu
dysfunction
dy ESRD Prior intubations
Myalgias Endocarditis Hemodi
Hemodialysis
emod Peritoneal dialysis Radiation exposure
Arthralgias GERD Sarc
Sarcoidosis Sleep study
Joint swelling Gout SSeizure disorder Steroid use, chronic
Claudication symptoms Hemolytic
lytic anemia Sleep Apnea CPAP BiPAP
Skin/Breasts Hepatic
patic dysfunction
sfunction Systemic Lupus Erythematosis Tuberculosis
Masses HIV/AIDSS Thrombocytopenia ITP TTP PPD Result Positive Negative Date
New skin lesions Hype
Hypertension
ertension Thyroid disease hypo hyper Tuberculosis Treatment
Sensitivity to sun
Malignancy
ignancy
Neurologic
Adrenal
renal Colon
on L
Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Headaches Stage
ge Treat
Treatment
T Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Seizures
CABG Splenectomy Organ transplant Lung resection Pleurodesis Other
e-
Muscle weakness Surg

Surgeries
Endocrinologic
Social History / Risk factors
So
Hair loss Deni
Denies Yes
D Ever smoker ___ # Packs X ____ # Yrs Recreational drug use Denies Yes Inhalation Injection Ingestion
Polydipsia D
Denies Yes Chews tobacco Drug dependence Denies Yes Narcotics Benzodiazepines
Tremors
Denies Yes Quit tobacco use Quit date _________ Alcohol use Denies Yes ___ Drinks per Day Week
Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Neck pain
Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade
Heme/Lymph Occupational and Exposure History
Bleeding gums
Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter
Unusual bruising
Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals
Swollen lymph nodes Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic
Allergy/Immunology Military Experience Chemicals or fires
Sinus problems
Recurrent infections Family Medical History
Asthma CHF COPD Coronary Artery Disease MalignancyPancreatitis Thrombotic disorder
©MB and RR 2006-2009 Revised 16Sep09 e-medtools.com Health Care Provider Signature
Exam To qualify as a comprehensive exam: General Multisystem requires performing ALL of 9 organ systems, AND 2 elements documented in each organ system
Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND 1 element in every other organ system is expected
Ventilator Constitutional ( 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam
Mode ACSIMV PC PRVC Height ___________ in cm Weight ___________ lb kg
Intubation date ____ / ____ / ____ Temperature __________ Pulse Rate __________ AND Rhythm Regular
egul Irregular
Blood Pressure sitting _____ / _____ OR standing _____ / _____ OR lying
ng _____ / _____
__
___
ETT size _____ PS ______ Respiratory Rate__________ nal Sa
Optional
onal Sats _____ % Cardiac Output _____ SVR _
S _____
Rate ______ Tidal Vol ______
Body habitus wnl Cachectic Obese
bese
ese
m
Grooming wnl Unkempt
PEEP ______ Plateau ______ ENT WNL = Within Normal Limits
ol E
FiO2 ______ PO2/FiO2 ______ WNL Edema
Nasal mucosa, septum, and turbinates
rbinates Edem or erythema presentt
Dentition and gums WNL
L D Ging
Dental caries Gingivitis
co
NonInvasive Ventilator
Oropharynx WNL Edema or erythema pre
present Oral ulcers
pres cers Oral Petechiae
CPAP BiPAP IE ____ to L
EE ____
Mallampati I II III
II IV
V
IV Medications Neck WNL = Within Normal Limits
imits
Antiarrhythmics Narcotics WNL NL Erythema or scarring consistent with

h recent or old radiatio
P
Neck radiation dermatitis
Antihypertensives Pressors Thyroid WNL Thyromegaly
yrome Nodules palpable
lpable Neck mass _____________________
____
_
Diuretics
Drotrecogin alfa
Sedation
Steroids
s. Resp WNL
ular Veins WNL JVD p
Jugular
ula
L = Within Normal Limits
present a, v or cannon a waves presen
present
ed M
Heparin Thrombolytic Chest
hest is free of defects
de
defects, expands normally nd symmetrically Erythema consistent with radiation dermatitis
rmally and
Insulin TPN Scarring consistent with old, healed radiation dermatitis Surgical scar present Scar, other
carring consis
consi
Antibiotics Resp effort WN WNL Accessory
W ory muscle use Intercosta
Intercostal
erco retractions Paradoxic movements
percussion WNL Dullness o percussion Lt Rt Hyperresonance Lt Rt
m A
Chest percus
percuss ness tto
Lines & Monitors
Telemetry Tactile fremitus
Ta fre WNL Increased rea Decreased
De
Decreas __________________________________
Chest tube Auscultation WNL
Aus
Auscu L Bronchial breath sounds
sound Egophony Rales Rhonchi Wheezes Rub present
soun
present absent CV
e- S
Left Air leak WNL = Within Normal Limits

W mits
Right Air leak present absent Clear S1 S2 No murmur, rub or ga gallop Gallop audible Rub audible
Trach present Size Murmur nt Systolic
ur present ystolic Diastolic Grade I II III IV V VI
Endotracheal tube Size Peripheral
al pulses palpable No peripheral edema Peripheral pulses Absent Weak
eripheral
NG/ND tube GI WNL = Within Normal Limits
PEG/PEJ tube Abdomen

n WNL Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
Foley catheter Liver and spleen ppa
palpation WNL Unable to palpate Liver Spleen Enlarged Liver Spleen
Ostomy 2 areas must be examined)
Lymph (2 ex WNL = Within Normal Limits
Central line/PICC Lymph nod

node exam WNL Neck Axilla Groin Other ___________________
Areas examined
Site
No sign of infection
Lymphadenopathy noted in
Lympha
Lymp Neck Axilla Groin Other ___________________
Musc
c WNL = Within
With Normal Limits
Peripheral venous access
Site M
Muscle tone WNL, and no atrophy noted Tone is Increased Decreased Atrophy present
No sign of infection Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Port access Extrem WNL = Within Normal Limits
Ex
No sign of infection Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Skin
Sk WNL = Within Normal Limits
Labs
No rashes, ecchymoses, nodules, ulcers Rash Bullae Pressure Ulcer Stage 1 2 3 4
\____/ ____ / ____ / ____ / Neuro WNL = Within Normal Limits
/ \ \ \ \ Oriented NOT oriented to Person Time Place
Affect is WNL OR Patient appears Agitated Anxious Depressed
Radiology Additional Findings Glasgow Coma Score E _____ V _____ M _____ APACHE II Score __________
CXR CT/Chest Other
Recommendations Impression
Aggressive pulmonary toilet I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
DVT prophylaxis decision maker) understands their medical condition and the consequences of their Code Status decision.
Stress ulcer prophylaxis Code Status Patient is a FULL CODE
Daily sedation vacation and DO NOT ATTEMPT RESUSCITATION, Cardiac or Pulmonary
neurologic assessment
Head of bed elevated > 30 Degrees This patient has advanced health care directives.
s. Their
T HCPOA is
Intense glycemic control 100-150
Central line change or removal
m
(send tip for culture)
Physical therapy
ol E
Enteral/Parenteral feeds
Supplemental IV Fluids
co
Smoking cessation aids
to L
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
Antiviral Treatment Prophylaxis
P
Oseltamivir
Zanamivir
Amantadine
s.
ed M
Ramantadine
Antibiotics
Diagnostics
m A
Metabolic Panel Basic Complete

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

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

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

Chronic Obstructive Pulmonary Disease Evaluation

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Chronic Obstructive Pulmonary Disease Evaluation

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COPD Evaluation Patient DOB MRN

Date Time Chief complaint/Reason for consult Referring MD

Symptomatic with minimal

ncreased sputum production

Weight changes Adrenall dysfunction

Muscle weakness Surg

Antiarrhythmics Narcotics WNL NL Erythema or scarring consistent with

Left Air leak WNL = Within Normal Limits

PEG/PEJ tube Abdomen

Central line/PICC Lymph nod

Metabolic Panel Basic Complete

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Chronic Obstructive Pulmonary Disease Evaluation

Uploaded by

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Copyright

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Chronic Obstructive Pulmonary Disease Evaluation

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COPD Evaluation Patient DOB MRN

Date Time Chief complaint/Reason for consult Referring MD

Symptomatic with minimal

ncreased sputum production

Weight changes Adrenall dysfunction

Muscle weakness Surg

 Antiarrhythmics  Narcotics  WNL NL Erythema or scarring consistent with

Left Air leak WNL = Within Normal Limits

PEG/PEJ tube Abdomen

Central line/PICC Lymph nod

Metabolic Panel Basic Complete

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Symptomatic with minimal

Weight changes Adrenall dysfunction

Antiarrhythmics Narcotics WNL NL Erythema or scarring consistent with

PEG/PEJ tube Abdomen

Central line/PICC Lymph nod

Metabolic Panel Basic Complete