June 21, 2007

Pleural Effusion MedicalTemplate Updated 6/18/07

An updated pleural effusion evaluation MedicalTemplate was released 6/18/07.

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Pleural Effusion Evaluation MRN Allergies Date Chief complaint/Reason for consult Start time Stop time Medications History of present illness ‰Pleuritic chest pain present ‰Dyspnea or cough ‰Peripheral edema ‰Orthopnea or PND ‰Decreased exercise tolerance ‰Recent fever, chills or nightsweats ‰Recent severe emesis or esophageal dilatation ‰Recent MI or cardiothoracic surgery ‰CHF, ESRD on HD, SLE, RA, Sarcoidosis ‰History of asbestos exposure ‰History of malignancy Drugs associated with pleural effusion include, but are not limited to: bromocriptine, cyclophosphamide, dantrolene, isotretinoin, mesalamine, methotrexate, mitomycin, nitrofurantoin, practolol, procarbazine Social History ‰ Tobacco use ____ Packs x ____ Yrs ‰ Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems See HPI WNL ‰ Alcohol use ______ Drinks per ‰ day ‰ week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day ‰ Recreational drug use ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych Fatigue, malaise, fever/chills, weight loss, change in appetite Vision changes, New pain, Scotomas Nose bleeds, dental caries, dental abscesses, jaw pain Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea Chest pain, diaphoresis, ankle edema, PND, syncope Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena Change in urinary habits, hematuria, dysuria Myalgias, recent trauma, bony fractures, arthralgias, joint swelling Rashes, new masses or skin lesions, increased sensitivity to sun Seizures, episodic or chronic muscle weakness Hair loss, polydipsia Bleeding gums, unusual bruising, swollen lymph nodes Sinus probs, recurrent infections Mood changes, agitation, psychosis, delirium, dementia Notes Family Medical History ‰ Congestive Heart Failure ‰ Coronary Artery Disease ‰ Malignancy ‰ Pancreatitis ‰ Renal Dysfunction ‰ Thyroid Disease Past Medical and Surgical History ‰ Asthma ‰ Cerebral Artery Disease ‰ Bronchiectasis ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ COP (BOOP) ‰ Diabetes ‰ Cystic Fibrosis ‰ GERD ‰ Histiocytosis ‰ Hepatic Dysfunction ‰ Tuberculosis ‰ HIV/AIDS ‰ PAH ‰ Hypertension ‰ Sarcoidosis ‰ Inflam bowel disease ‰ Tuberculosis ‰ Malignancy ‰ Neuromuscular weakness ‰ Occupational exposures ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Scleroderma ‰ Seizure Disorder ‰ Sjogren ‰ Renal Dysfunction ‰ Rheumatoid arthritis ‰ Thrombotic Disease ‰ Thyroid Disease ‰ Chemotherapy ‰ Colonoscopy ‰ ECHO/Stress Test ‰ Mammogram ‰ PFTs ‰ PapSmear ‰ Prior Intubations ‰ Radiation exposure ‰ Sleep Study ‰ Steroid use Notes ©MB and RR 2006, 2007 Revised 24April07 Pleural Effusion Evaluation Vitals _____ _____ Weight Height Exam General ENT _____ Temperature ___________ BP Sitting ___________ BP Standing Sats Rest _____ Pulse _____ Exercise 50 feet _____ 100 feet _____ _____ _____ ‰ Alert ‰ Nasal mucosa ‰ Dentition ‰ Oropharynx Mallampati ‰I ‰II ‰III ‰IV Neck ‰ Normal to palpation ‰ Thyroid ‰ No JVD Resp ‰ Clear to auscultation ‰ Dullness to percussion ‰No respiratory distress ‰No chest wall defects ‰ Decreased fremitus ‰ Bronchial breath sounds ‰ Absence of intercostal respiratory retractions ‰ Egophony (E to A change) CV ‰ Clear S1 S2 ‰ No murmur ‰ No gallop ‰No rub ‰ Peripheral pulses ‰ No peripheral edema GI ‰No palpable masses ‰ Liver and spleen not palpable ‰ No hepatojugular reflux Lymph ‰ No lymphadenopathy Musc ‰Tone ‰ Gait Extrem ‰ No clubbing ‰ No cyanosis Skin ‰ No rashes, ecchymoses, nodules, ulcers Neuro ‰ Oriented œ58(Pts with Community Acquired Bacterial Pneumonia) ‰Affect Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Labs/Tests ‰CXR (PA, lateral, lateral decubitus) ‰CT of chest ‰PET scan ‰MRI ‰Thoracentesis ‰Pleural fluid ‰Glucose ‰LDH, include serum level ‰pH ‰Protein, include serum level ‰Cell count with differential ‰Cultures: bacterial, fungal, AFB (all suspected exudates) ‰Cytology (suspected exudates) ‰Adenosine deaminase (for TB) ‰Amylase (for suspected pancreatitis or ruptured esophagus) ‰ANA, RF (for suspected autoimmune disease) (all suspected exudates) (PE protocol if PE suspected) DDx includes, but is not limited to: Pulmonary embolism, Tuberculous pleurisy, Infection, hepatitis, esophageal rupture of any cause or recent sclerotherapy, malignancy, pancreatitis, congestive heart failure, renal failure, hemothorax, uremic pleurisy, sarcoidosis, post-cardiac injury syndrome or coronary artery bypass graft surgery, ARDS, lupus, rheumatoid pleurisy, MCTD, hypothyroidism, urinothorax, SVC obstruction, trapped lung, hypoalbuminema, cirrhosis, atelectasis, pericarditis Imperative rule outs: PE and tuberculous pleurisy => due to increased morbidity if left undiagnosed ‰Flow cytometry ‰Hematocrit (for bloody effusion) ‰Pleural biopsy ‰Triglyceride, cholesterol levels (for suspected chylothorax or pseudochylothorax) ‰Urea (for suspected urinothorax) (for suspected TB or malignancy) (for suspected lymphoma) Exudate if: Pleural:serum protein >0.5 Pleural:serum LDH >0.45 pleural LDH >2/3 upper limit normal for serum If patient history of diuretic use: Serum -- pleural protein = <3.1 g/dL suggests exudate Pleural LDH of >1000 suggests empyema, malignancy, rheumatoid lung effusion or paragonimiasis ‰ Patient has completed advanced health care directivesœ47 HCPOA is Signature ©MB and RR 2006, 2007 Revised 24April07

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