October 1, 2007

New Pulmonary Artery Hypertension MedicalTemplate

A new pulmonary artery hypertension MedicalTemplate was released 10/1/07.

The pulmonary artery hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected pulmonary artery hypertension in inpatient and ambulatory settings.


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Read this document on Scribd: Pulmonary Arterial Hypertension Evaluation

Pulmonary Arterial Hypertension Evaluation Date Start time Stop time Allergies History of present illness ‰Fatigue, weakness ‰Cough ‰Pain ‰Decreased appetite ‰Hemoptysis ‰Weight loss ‰Calcinosis ‰Raynaud’s ‰Esophageal dysfunction ‰Sclerodactyly ‰Telangiectasias ‰Dyspnea ‰Asymptomatic with usual activity ‰Symptomatic with usual activity ‰Symptomatic with minimal activity ‰Symptomatic at rest Chief complaint/Reason for consult MRN ‰Allergy list reviewed ‰ No drug allergies ‰ No food allergies Medications ‰Medication list reviewed ‰Med list reconciled with Nursing Home, Skilled Nursing facility or Rehab facility med list œ46 Social History ‰ Tobacco use ____ Packs x ____ Yrs ‰Chronic exposure to second hand smoke Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems See HPI WNL ‰ Quit ‰ 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 ‰Inhalational ‰Injectable ‰Ingestible ‰ Drug dependence ‰Narcotics ‰Benzodiazepines Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych Occupational History ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ Fatigue, malaise, change in appetite Vision changes, new pain, scotomas Nose bleeds, dental Caries, dental abscesses, jaw pain Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness 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 or redness Rashes, new masses or skin lesions, increased sensitivity to sun exposure Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor Hair loss, polydipsia, polyuria, gynecomastia Bleeding gums, unusual bruising, swollen lymph nodes Sinus probs, recurrent infections, anaphylaxis Mood changes, agitation, psychosis, delirium, dementia Family Medical History ‰ AV Malformations ‰ Pulmonary Hypertension ‰ Rheumatoid Arthritis ‰ Scleroderma ‰ Systemic Lupus Erythematosus ‰ Malignancy ‰ Breast ‰ Colon ‰ Lung ‰ Melanoma ‰ Prostate ‰ Renal cell ‰ Testicular ‰ Thyroid ‰ Other Past Medical and Surgical History ‰ Asthma ‰ Appetite Suppressant Use ‰ Neuromuscular weakness ‰ Bronchiectasis ‰ AV Malformations ‰ Occupational exposures ‰ Cryptogenic Organizing Pneumonia (BOOP) ‰ Cerebral Artery Disease ‰ Peripheral Artery Disease ‰ COPD ‰ Congenital Heart Defects ‰ Scleroderma ‰ Cystic Fibrosis ‰ Left to Right Shunt ‰ Seizure Disorder ‰ Histiocytosis ‰ Atrial Septal Defect ‰ Sjogren ‰ Obstructive Sleep Apnea ‰ Ventricular Septal Defect ‰ Systemic Lupus Erythematosus ‰ CPAP ‰ BiPAP ‰ Patent Ductus Arteriosus ‰ Renal Dysfunction ‰ Tuberculosis ‰ Congestive Heart Failure ‰ Rheumatoid Arthritis ‰ Pulmonary Arterial Hypertension ‰ Coronary Artery Disease ‰ Thrombotic Disease ‰ Pulmonary fibrosis ‰ Dermatomyositis/Polymyositis ‰ Thyroid Disease ‰ Pulmonary Thromboembolic Disease ‰ Diabetes ‰ Malignancy ‰ Pulmonary Venoocclusive Disease ‰ Diastolic Dysfunction ‰ Breast ‰ 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 Weight BMI Temperature BP Pulse Sats At Rest With Activity CVP Cardiac Output Urine Output Last 24 hours Last 8 hours Exam ✔ ‰ Checked box indicates findings are within normal limits ‰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 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 ‰Affect General ENT Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Schedule Patient For Labs/Tests ‰LFTs ‰Hepatitis Panel ‰HIV ‰TSH ‰CBC ‰BMP ‰D-dimer ‰ESR ‰Phospholipid Ab ‰RF ‰dsDNA Ab ‰ssDNA Ab ‰Centromere Ab ‰Topoisomerase I Ab (Scl-70) ‰U1RNP Ab ‰Jo-1 Ab ‰Pulmonary Function Testing ‰Methacholine Challenge ‰6 Minute Walk Test ‰CXR ‰Chest CT ‰with contrast ‰V/Q Scan ‰ECHO ‰With Bubble study ‰Assess PA pressures ‰Cardiopulmonary Stress Test ‰Sleep Study ‰Bronchoscopy ‰Pneumococcal vaccine ‰Influenza vaccine Signature ‰Patient has completed advanced health care directivesœ47 Health Care Power Of Attorney is Code Status ‰Full code ‰Do Not Attempt Resuscitation ‰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



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