COPD Eva Evalua luation tion Date
Patie Pat ient nt
Time
MRN
Chief complaint/Reason for consult
Yes Constitution Fatigue or Malaise
DOB
Referring MD
No
History of Present Illness Patient is Nonverbal. Nonverbal. History obtained from Family Medical records
Fever or chills Appetite changes Eyes Vision changes New eye pain ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain
Recent Antibiotic use
Respiratory Dyspnea
dmi Recent Oral steroid use Recent Hospital admissions
Recent ER visits
nt Weightt loss l or decreased appetite petite Recent
.
lanned air tr travel in near future Planned
in previous ou 12 months Spirometry evaluation performed within
Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes
COPD Symptoms
FEV1/FVC F V
FEV1 E
S SEVERITY
Asymptomatic with usual activity
% 70%
>80% 80% %
At risk
ity Symptomatic with usual activity
<70% 0% <70%
>79%
Mild
acti activity ti Symptomatic with minimall ac
< 70%
5 50-79% Moderate
Symptomatic at rest
<7 <70%
30-49% Severe
<70% 0%
<30%
Chronic hronic h r Bronchitis tis s symptoms cough co IIncreased coug nc dyspnea dy d IIncreased Increased rease sputum production Increase
Very Severe
Medications
Allergies rg
iew d Medications reviewed
lle List reviewed Allergy
cile with Nursing Nu in Home or Hospital discharge Information on 46 Medications reconciled
No food or drug allergies
Past Medical, Medica e l, Family ily Social History Asthma
atory Bowel Disease Dis Inflammatory
Chemotherapy
dysf dy un unction unction Adrenal dysfunction
romuscular ular weakness wea ss Neuromuscular
Colonoscopy
Notes
Constipation or Diarrhea
Arthritis A Arthritis RA
steoporosis os Osteoporosis
ECHO/Stress test
Abdominal pain
DV PE Blood clots DVT
ns Organ transplant
Immunosuppressive therapy
Genitourinary Hematuria
C CHF
anc ancreatitis is Pancreatitis
Mammogram
COPD
eripheral he Artery r Disease Di Peripheral
Organ failure
Dysuria
Coronary nar Artery Disease Coronar
ituitary iinfarct n c or or hemorrhage Pituitary
PFTs
Urethral discharge
Cystic Fibrosis Cyst Cysti
rotein r ot ot deficiency deficii Protein C S
Pap Smear
Musculoskeletal Myalgias
Diabetes 1 2 enal al dysfunction dys D Renal ESRD
Prior intubations
Endocarditis
emo o Hemodialysis Peritoneal dialysis
Radiation exposure
Arthralgias
GERD
Sarcoidosis Sar
Sleep study
Joint swelling
Gout
Seizure disorder
Steroid use, chronic
Claudication symptoms
i c anemia nemia Hemolytic
Sleep Apnea CPAP BiPAP
atic dysfunction unction unct ion Hepatic
Systemic Lupus Erythematosis
Tuberculosis
IV/AIDS HIV/AIDS
Thrombocytopenia ITP TTP
PPD Result Positive Negative
ypertension rte ion Hypertension
Thyroid disease hypo hyper
Tuberculosis Treatment
Skin/Breasts Masses New skin lesions Sensitivity to sun Neurologic Headaches
Date
Malignancy Adrenal nal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx Stage Treatment Trea
Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology
Surgeries CABG Splenectomy Organ transplant Social History / Risk factors
Lung resection Pleurodesis Other
Denies Yes Ever smoker ___ ___ # Packs X ____ # Yrs Recreational drug use Denies Yes Inhalation Injection Ingestion De Drug dependence Denies Yes Narcotics Benzodiazepines Denies Yes Chews tobacco
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 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
Sinus problems Recurrent infections
Family Medical History Asthma CHF COPD Coronary Artery Disease Malignancy Pancreatitis Thrombotic disorder
©MB and RR 2006-2009
Revised 16Sep09
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Health Care Provider Signature
COPD Eva Evalua luation tion Exam
Patie Pat ient nt
DOB
MRN
General Multisystem requires performing ALL of 9 organ systems, systems, AND 2 elements documented in each organ system
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 ACSIMV PC PRVC
Constitutional ( 3 vitals) Body habitus and Grooming Grooming required required of General Multisystem but not Organ System Exam Height ___________ in cm
Weight ___________ lb kg
ETT ET T si size ze ___ _____ __ PS
______
Temperature __________ Pulse Rate __________ AND Rhythm Regular Irregular Blood Pressure sitting _____ / _____ OR OR standing standing _____ _____ / _____ OR OR lying lying _____ / _____ __ Respiratory Rate __________ Optional Sats _____ Sats _____ % Ca Card rdia iac c Outp Output ut _____ _____ ____ SVR _____ al S
Rate ______ Tidal Vol
______
se Body habitus wnl Cachectic Obese
Intuba Int ubation tion dat date e ___ ____ _ / ____ ____ / ____ ____
PEEP ______
Plateau
FiO2 ______
PO2/FiO2 ______
______
Grooming wnl Unkempt ENT
WNL = Within Normal Limits
Nasal mucosa, septum, and turbinates inates Dentition and gums WNL
NonInvasive Ventilator
Oropharynx
CPAP BiPAP IE ____ ____ EE ____ ____ IV Medications Antiarrhythmics Antihypertensives Diuretics Drotrecogin alfa Heparin Insulin Antibiotics
Thyroid WNL N
Sedation
sign of infection
NL JVD VD D present a, v or cannon n a waves ves present prese WNL
WNL = Within Wit h Normal Limits L
Chest es is free ee of defec defects, d expands normally ally and symmetrically m ally Erythema consistent with radiation dermatitis rri cons consistent with old, healed aled radiation d dermatitis d tit Surgical scar present Scar, other Scarring Chest hest e percussion percu WNL
WNL Tactile fremitus T fr WNL Auscultation Aus u CV
Dullness ss to to percussion cus Dullness Lt Rt Hyperresonance Lt Rt
Increased Decrea ea Decreased __________________________________ Decreased D __________________________________
Bronchial Egophony Rales Rhonchi Wheezes Rub present r n lb breath soun sounds u
WNL = Within Normal Limits s
murmur, ru rub or or gallop Gallop audible Rub audible Clear S1 S2 No m
Murmur presentt Systolic Diastolic Grade I II III IV V VI to Peripheral pheral pulses s palpable No peripheral edema GI
Peripheral pulses Absent Weak
WNL = Within Normal or Limits Lim
Abdomen n
Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile WNL Ma
iv and d spleen spleen spleen n palpation palpation WNL Unable to palpate Liver Spleen Liver
-
Lymph ( 2 areass must be examined)
Enlarged
Liver Spleen
WNL = Within Normal Limits
Lymph nod no node exam exam WNL Areas examined examined Neck Axilla Groin Other ___________________
Musc
Lymphadenopathy Lymph y noted in
Neck Axilla Groin Other ___________________
WNL = Within Normal Limits
atrophy noted Tone is Increased Decreased Atrophy present Muscle tone WNL, and no atrophy
Site
Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
sign of infection
Port access
Extrem WNL = Within Normal Limits
on sign of infecti on
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Labs \____/ / \
o able N Neck mass __ _____________________ ________________ _____ Thyromegaly Nodules palpable
Resp effort e s Intercos Intercostal rc retractions Paradoxic movements WNL Accessory muscle use
Peripheral venous access
No
Jugular ar Veins
Resp
Thrombolytic TPN
Site
No
WNLL Erythema yth m or scarring scarrin consistent with recent or or old d radiation ra radiat a dermatitis
Neck
Pressors
Lines & Monitors Telemetry Chest tube Left Air leak present absent Right Air leak present absent Trach present Size Endotracheal tube Size NG/ND tube PEG/PEJ tube Foley catheter Ostomy Central line/PICC No
III III IV
WNL = Within Normal Limits mit
Narcotics
Steroids
Gingivitis Gin Gi
pr pre ers Oral ral Petechiae Pe WNL Edema oorr erythema present Oral ulcers
Mallampati I
Neck
WNL NL Ede Edema e or erythema present esent
Dental caries
Skin
WNL = Within Normal Limits
Neuro
WNL = Within Normal Limits
No rashes, ecchymoses, nodules, ulcers Rash Bullae Pressure Ulcer Stage 1 2 3 4 ____ / ____ / ____ / \ \ \
Oriented NOT oriented to Person Time Place Affect is WNL OR OR Patient Patient appears Agitated Anxious Depressed
Radiology CXR CT/Chest Other
©MB and RR 2006-2009
Additional Findings
Revised 16Sep09
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Glasgow Coma Score E _____ V _____ M _____
Health Care Provider Signature
APACHE II Score __________
COPD Eva Evalua luation tion
Patie Pat ient nt
Recommendations
DOB
MRN
Impression
Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis
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
Daily sedation vacation and neurologic assessment
Head of bed elevated > 30 Degrees Intense glycemic control 100-150 Central line change or removal (send tip for culture) culture)
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 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
E o L c P l s . M o A t o d e m -
health care directives. directives. Their HCPOA is This patient has advanced health
Serum mycoplasma 12-lead EKG Echocardiogram Chest x-ray PA and Lateral Decubitus CT of chest
Signature cc
Other
©MB and RR 2006-2009
Revised 16Sep09
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Health Care Provider Signature
