Pulmonary Arterial Hypertension Evaluation

Date Chief complaint/Reason for consult MRN

Start time
Stop time
Allergies History of present illness
‰Allergy list reviewed ‰Fatigue, weakness 
‰Cough

‰ No drug allergies ‰Pain
‰ No food allergies ‰Decreased appetite
‰Hemoptysis
‰Weight loss
‰Calcinosis www.e-medtools.com
‰Raynaud’s
Medications ‰Esophageal dysfunction
‰Sclerodactyly
‰Medication list reviewed ‰Telangiectasias
‰Med list reconciled with 
Nursing Home, Skilled ‰Dyspnea 
Nursing facility or Rehab facility www.e-medtools.com
‰Asymptomatic with usual activity
med list œ46 ‰Symptomatic with usual activity
‰Symptomatic with minimal activity
‰Symptomatic at rest

Social History Review of Systems

‰ Tobacco use
See HPI WNL
www.e-medtools.com
____ Packs x ____ Yrs ‰ Quit
‰‰ Constitutional Fatigue, malaise, change in appetite
‰Chronic exposure to second hand smoke ‰‰ Eyes Vision changes, new pain, scotomas
Daily, occasional and ex-smokers are ‰‰ ENT/mouth Nose bleeds, dental Caries, dental abscesses, jaw pain
more likely to be hazardous drinkers ‰‰ Resp Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness
‰ Alcohol use ‰‰ CV Chest pain, diaphoresis, ankle edema, PND, syncope
‰‰ www.e-medtools.com
GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena
______ Drinks per
‰ day ‰ week ‰‰ GU Change in urinary habits, hematuria, dysuria
Hazardous drinking ‰‰ Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling or redness
NIAAA (National Institute on ‰‰ Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun exposure
Alcoholism and Alcohol Abuse ‰‰ Neuro Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor
guidelines)
‰‰ Endo Hair loss, polydipsia, polyuria, gynecomastia
Men > 14 drinks per week OR
‰‰ Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes
‰‰www.e-medtools.com
> 4 drinks per day
Women > 7 drinks per week OR Allergy/Immun Sinus probs, recurrent infections, anaphylaxis
>3 drinks per day ‰‰ Psych Mood changes, agitation, psychosis, delirium, dementia
 Occupational History
‰ Recreational drug use
‰Inhalational ‰Injectable ‰Ingestible
‰ Drug dependence www.e-medtools.com
‰Narcotics ‰Benzodiazepines

Family Medical History Past Medical and Surgical History

‰ AV Malformations ‰ Asthma ‰ Appetite Suppressant Use ‰ Neuromuscular weakness
‰ Pulmonary Hypertension ‰ Bronchiectasis ‰ AV Malformations ‰ Occupational exposures
‰ Rheumatoid Arthritis ‰ Cryptogenic Organizing Pneumonia (BOOP) ‰ Cerebral Artery Disease ‰ Peripheral Artery Disease
‰ Scleroderma ‰ COPD ‰ Congenital Heart Defects ‰ Scleroderma
‰ Cystic Fibrosis ‰ Left to Right Shunt ‰ Seizure Disorder
‰ Systemic Lupus Erythematosus
‰ Histiocytosis ‰ Atrial Septal Defect ‰ Sjogren
‰ Malignancy ‰ Obstructive Sleep Apnea ‰ Ventricular Septal Defect ‰ Systemic Lupus Erythematosus
‰ Breast
‰ Colon ‰ CPAP ‰ BiPAP ‰ Patent Ductus Arteriosus ‰ Renal Dysfunction
‰ Lung ‰ Tuberculosis ‰ Congestive Heart Failure ‰ Rheumatoid Arthritis
‰ Melanoma ‰ Pulmonary Arterial Hypertension ‰ Coronary Artery Disease ‰ Thrombotic Disease
‰ Prostate ‰ Pulmonary fibrosis ‰ Dermatomyositis/Polymyositis ‰ Thyroid Disease
‰ Renal cell ‰ Pulmonary Thromboembolic Disease ‰ Diabetes ‰ Malignancy
‰ Testicular ‰ Pulmonary Venoocclusive Disease ‰ Diastolic Dysfunction ‰ Breast
‰ Thyroid
‰ Other ‰ Sarcoidosis ‰ Nocturnal GERD ‰ Colon
‰ Tuberculosis ‰ Hepatic Dysfunction ‰ Lung
Surgeries ‰ HIV/AIDS ‰ Melanoma
    ‰ Hypertension ‰ Prostate
    ‰ Inflammatory Bowel Disease ‰ Renal cell
    ‰ Mitral Stenosis or Regurgitation ‰ Testicular
    ‰ Mixed Connective Tissue Disorder ‰ Thyroid
    ‰ Myocarditis/Pericarditis ‰ Other

©MB and RR 2006, 2007 Revised 26Sep07

Pulmonary Arterial Hypertension Evaluation
Vitals Exam ‰
✔ Checked box indicates findings are within normal limits

Weight

BMI
General‰Alert
ENT ‰Nasal mucosa ‰Dentition ‰Oropharynx Mallampati ‰I ‰II ‰III ‰IV
Neck ‰Normal to palpation ‰Thyroid ‰No JVD
Temperature

BP Resp ‰Clear to auscultation ‰Dullness to percussion ‰No respiratory distress ‰No chest wall defects
Pulse ‰Decreased fremitus ‰Bronchial breath sounds
CV ‰Clear S1 S2 ‰No murmur ‰No gallop ‰No rub ‰Peripheral pulses ‰No peripheral edema
www.e-medtools.com
GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux
Sats
At Rest
Lymph ‰No lymphadenopathy
With Activity
Musc ‰Tone ‰Gait
CVP Extrem ‰ No clubbing ‰No cyanosis
www.e-medtools.com
Cardiac Output Skin ‰No rashes, ecchymoses, nodules, ulcers
Neuro ‰Oriented ‰Affect
Urine Output
Last 24 hours
Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Last 8 hours www.e-medtools.com
Labs/Tests Impression and Plan
‰LFTs Schedule Patient For
‰Hepatitis Panel ‰Pulmonary Function Testing
‰HIV ‰Methacholine Challenge
‰TSH ‰6 Minutewww.e-medtools.com
Walk Test
‰CBC ‰CXR
‰BMP ‰Chest CT ‰with contrast
‰D-dimer ‰V/Q Scan
‰ESR ‰ECHO
‰Phospholipid Ab ‰With Bubble study
‰RF ‰Assesswww.e-medtools.com
PA pressures
‰dsDNA Ab ‰Cardiopulmonary Stress Test
‰ssDNA Ab ‰Sleep Study
‰Centromere Ab ‰Bronchoscopy
‰Topoisomerase I Ab (Scl-70) 
‰U1RNP Ab www.e-medtools.com
‰Pneumococcal vaccine
‰Jo-1 Ab ‰Influenza vaccine

Signature
‰Patient has completed advanced health care directivesœ47 Code Status ‰Full code ‰Do Not Attempt Resuscitation
Health Care Power Of Attorney is

‰Continuous home oxygen Tx Flow rate ____________L/min

‰Concentrator ‰Tank with conservation valve ‰Nasal cannula with reservoir ‰Portable tank ‰Gas ‰Liquid

‰Supplemental oxygen therapy during air travel Flow rate ____________L/min

Home ‰CPAP ‰BiPAP Flow rate ____________L/min
‰Heater and humidifier Mask type ‰Nasal ‰Oronasal ‰Face

©MB and RR 2006, 2007 Revised 26Sep07