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Pulmonary and Critical Care New Patient Evaluation Template Referring Physician ‰Patient has advanced care directives œ47 Name of HCPOA/Surrogate Reason for consult History of Present Illness ‰Patient is Nonverbal. History obtained from Date PCP Start time Stop time Allergies ‰ Family ‰ Medical records ‰ Allergies reviewed ‰ No drug allergies ‰ No food allergies Review of Systems See HPI WNL ‰ >/= 2 Falls within past 12 months, OR 1 which resulted in injury œ4 Medications ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ 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 Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, 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 Rashes, nonhealing areas, new masses New paresthesias, gait abnormalities, seizures, muscle weakness Hair loss, polydipsia Bleeding gums, unusual bruising, swollen lymph nodes Sinus probs, recurrent infections Mood changes, agitation, psychosis, delirium, dementia ‰ Medications reviewed ‰ Med list reconciled with ‰Hospital ‰ SNF ‰ Rehab Facility (Skilled Nursing Facility) œ46 discharge meds from Past Medical History ‰ Asthma ‰ Cerebral Artery Disease ‰ Bronchiectasis ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ COP (BOOP) ‰ Diabetes ‰Type I ‰Type II ‰ Cystic Fibrosis ‰ GERD ‰ Langerhan’s histiocytosis ‰ Hepatic Dysfunction ‰ Tuberculosis ‰ HIV/AIDS ‰ Pulmonary Hypertension ‰ Hypertension ‰ Sarcoidosis ‰ Inflammatory bowel disease ‰ Tuberculosis ‰ Malignancy ‰ Wegener’s Granulomatosis ‰ Pulmonary Alveolar Proteinosis Notes ‰ Narcolepsy ‰ Obstructive Sleep Apnea ‰ Restless Legs Syndrome Vaccines ‰ Neuromuscular weakness ‰ Occupational exposures ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Scleroderma ‰ Seizure Disorder ‰ Sjogren ‰ Renal Dysfunction ‰ Rheumatoid arthritis ‰ Thrombotic Disease ‰ Thyroid Disease Tests performed ‰ Chemotherapy ‰ Colonoscopy ‰ ECHO/Stress Test ‰ Mammogram ‰ PFTs ‰ PapSmear ‰ Prior Intubations ‰ Radiation exposure ‰ Sleep Study ‰ Steroid use Surgical History ‰Flu ‰Pneumo ‰BCG ‰Tetanus ‰ Quit ‰Pertussis ‰Varicella ‰ Malignancy ‰ Neuromuscular Disease ‰ Pancreatitis ‰ Periph Artery Disease ‰ Renal Dysfunction ‰ Seizure Disorder ‰ Thrombotic Disorder ‰ Thyroid Disease Social History ‰ Tobacco use ______ Packs x ______ Yrs ‰ Alcohol use ______ Drinks per ‰ day Family Medical History ‰ Asthma ‰ Cerebral Artery Disease ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ Diabetes ‰Type 1 ‰Type 2 ‰ Hepatic Dysfunction ‰ Hypertension IV Medications Daily, occasional and ex-smokers are more likely to be hazardous drinkers ‰ week Hazardous drinking (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 Exposure to ‰ Hot tub, Sauna, Jacuzzi, Humidifier ‰ Pressure washings ‰ Pets/Feathers ‰ Chemicals ‰ Organic/Inorganic dusts ‰ Other ©MB and RR 2006, 2007 Revised 24April07 Occupations and Hobbies Travel history ‰ Pressors ‰ Diuretics ‰ Heparin ‰ Thrombolytic ‰ Insulin ‰ Sedation ‰ Steroids ‰ Antibiotics ‰ TPN ‰ Narcotics ‰ Antiarrhythmics ‰ Antihypertensives www.e-medtools.com œIndicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Pulmonary and Critical Care New Patient Evaluation Template Vitals œ56 Ventilator Settings Mode Rate Tidal Vol Pts with CABP (Community Acquired Bacterial Pneumonia) Date PEEP PS Start time FiO2 Stop time PO2/FiO2 Plateau Pressure T P R BP Wt Satsœ57 Pts with CABP *General *ENT *Neck *Resp *CV *GI Lymph Musc Extrem Skin Neuro ‰ Alert ‰Checked box indicates findings are within normal limits ‰ Nasal mucosa ‰ Dentition ‰ Oropharynx Mallampati ‰I ‰II ‰III ‰IV ‰ Normal to palpation ‰ Thyroid ‰ No JVD ‰ Clear to auscultation ‰ Clear to percussion ‰No respiratory distress ‰No chest wall defects ‰ Clear S1 S2 ‰ No murmur ‰ No gallop ‰No rub ‰ Peripheral pulses ‰ No peripheral edema ✔ I/O UO(ml/kg/hr) CVP PCWP SVR ‰No palpable masses ‰ No hepatosplenomegaly ‰ No hepatojugular reflux ‰ No lymphadenopathy ‰Tone ‰ Gait ‰ No clubbing ‰ No cyanosis ‰ No rashes, ecchymoses, nodules, ulcers ‰ Oriented œ58(Pts with CABP) ‰Affect Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Labs/Tests Impression/Plan This patient may benefit from ‰Aggressive pulmonary toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Daily sedation vacation ‰Head of bed elevated > 30 Degrees at all times ‰Intense glycemic control ‰Pneumonia vaccine prior to discharge ‰Influenza vaccine prior to discharge ‰Changing central lines (sending tip for culture) ‰Physical therapy ‰Enteral/Parenteral feeds ‰Smoking cessation aids ‰Pulmonary Rehabilitation ‰PPD Testing ‰12-lead EKG ‰Echocardiogram ‰Carotid Dopplers, neck CT angiography, MR angiographyœ11 ‰CT or MRI of head within 24 hours of admissionœ10 ‰Aspirin within 24 hours of admission for AMI œ28 ‰Beta-blocker therapy ‰ACE Inhibitor/ARB therapyœ5 (Pts with ischemic stroke or transient ischemic attack) (Pts with ischemic stroke or transient ischemic attack) (Pt with AMI, CAD + prior MI, and Heart failure + left ventricular dysfunction) œ29, 7,8 (Pts with heart failure + left ventricular dysfunction) ‰Empiric antibiotics for CABP œ59 (Community Acquired Bacterial Pneumonia) Data Reviewed: ‰ ER Notes ‰ Old Chart Signature/Date: CODE STATUS: ‰ Full code ‰ Do Not Attempt Resuscitation ‰EMS Note ‰ECG ‰Nursing Notes & Vitals log ‰ Labs ‰ X Rays ‰MRI ‰US ‰CT ‰PFTs Coordination of care: ‰Discuss w/ER MD ‰Discuss w/HCPOA ‰Discuss w/PCP ‰Case Mgmt or SW ‰Pharmacy ‰Nutrition team ‰Physical therapy ‰Respiratory therapy ‰Nursing ©MB and RR 2006, 2007 Revised 24April07 www.e-medtools.com œIndicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Pulmonary and Critical Care New Patient Evaluation Template Definitions Sepsis Positive blood culture AND Heart rate !e 90 Temp e 36 C or !e 38 C Resp rate !e 20 OR PCO2 e 32 on ABG WBC e 4000 OR !e 12000 OR !e 10% Bands Without a positive blood culture, the above findings are consistent with Systemic Inflammatory Response Syndrome (SIRS) Date Start time Stop time Physiologic Score Temp ______ HR MAP RR Oxygenation ______ ______ ______ ______ ______ ______ APACHE II Score - To be obtained within first 24 hours of ICU Admission APACHE II: a severity of disease classification system Crit Care Med 1985 13(10):818-29 An evaluation of outcome from intensive care in major medical centers Ann Intern Med 1986 104(3):410 Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II and III prognostic systems in a United Kingdom intensive care unit Crit Care Med 1997 25(1):9-15 Physiologic Variable 0 1 2 3 4 Temperature 96.8-101.2 101.3-102.1 89.6-93.1 102.2-105.7 >105.7 93.2-96.7 Heart Rate 70-109 n/a 110-139 140-179 >161 55-69 40-54 < 50 MAP (2 x DBP + SBP)/3 Resp Rate 70-109 12-24 n/a 25-34 10-11 110-129 50-69 6-9 130-159 35-49 >181 <40 >49 <6 Serum Na Serum K Severe Sepsis The patient must meet the above criteria AND have hypotension, hypoperfusion or organ dysfunction. Hypotension is defined as SBP < 90 MAP e 70 mmHg OR drop of >/= 40 mmHg Oxygenation If FiO2 > 49%, A-a If FiO2 < 50%, PO2 Serum Na+ < 200 >70 130-139 61-70 150-154 200-349 350-499 55-60 >500 <54 >179 < 111 >7.1 < 2.5 >3.4 >7.69 <7.15 >39 <1.0 >59 <20 Serum Creatinine ______ Art pH WBC Hct GCS ______ ______ ______ ______ 155-159 120-129 2.5-2.9 160-179 111-119 6.0-6.9 Serum K+ 3.5-5.4 5.5-5.9 3.0-3.4 n/a 7.50-7.59 Septic Shock The patient must meet the above criteria AND have refractory shock (hypotension not responsive to fluid resuscitation). Systolic BP e 90,or MAP e 70 Serum Creatinine (Double if in ARF) Arterial pH 0.6-1.4 7.33-7.49 1.5-1.9 <0.6 7.25-7.32 2.0-3.4 7.60-7.69 7.15-7.24 n/a 15 – GCS Score (Eye + Motor + Verbal) Physiology Score ______ Glasgow Coma Score Eye response _____ 1 -None 2 - Eyes open to pain 3 - Opens to verbal command 4 - Open spontaneously Verbal response _____ 1 – None 2 – Incomprehensible sounds 3 – Inappropriate words 4 – Confused 5 – Oriented Motor Response _____ 1 – None 3 – Flexion to pain 4 – Withdrawal from pain 5 – Localizes pain 6 – Obeys commands Total Score < 9 indicates severe brain injury LANCET (ii) 81-83, 1974. WBC 3.0-14.9 15-19.9 20-39.9 1.0-2.9 50-59.9 20-29.9 Acute Lung Injury Bilateral infiltrates on radiograph PO2/FiO2 201-300 regardless of PEEP No evidence of elevated left atrial pressure OR PCWP < 18 mmHg Hematocrit GCS Score = 15 – GCS Score (Eye + Motor + Verbal) 30-45.9 46-49.9 n/a Acute Respiratory Distress Syndrome (ARDS) PO2/FiO2 e 200 Sepsis Treatment Goals Institute for Healthcare Improvement (www.ihi.org) 1. Blood cultures before administration of broad spectrum antibiotics 2. Broad spectrum antibiotics given in/= 70% OR SvO2 >/= 65% in 74 =6 Age Score ______ Predicted Mortality Based on APACHE II Score Score 5-9 10-14 15-19 20-24 25-29 30-34 over 34 Interpretation ~4% death rate ~8% death rate ~15% death rate ~25% death rate ~40% death rate ~55% death rate ~75% death rate ~85% death rate Total APACHE II Score ______ 0-4 Ventilator Strategies (www.ihi.org) 1. Head of bed elevated by >/= 30 degrees 2. Daily sedation vacation AND assessment of ability to wean from ventilator 3. Stress ulcer prophylaxis 4. Deep Venous Thrombosis prophylaxis Oxygen Coverage PO2e 55 OR Sats e 90% PO2 56-59 OR Sats 89% WITH CHF Cor pulmonale P wave >2mm lead II, III or AVF Hct >56% Sats e 88% for >5 minutes during sleep NOT COVERED PO2 >59 OR Sats >89% General Acid-Base Rules Acidosis Acute Resp pH = -0.008 x PCO2 HCO3 = 0.1 x PCO2 (+/-3) Chronic Resp PCO2 = 2.4(HCO3) – 22 HCO3 = 0.35 x PCO2 (+/-4) Metabolic PCO2 = 1.5(HCO3) + 8 +/-2 PCO2 ~ last 2 digits pH PCO2 = 1.2 x HCO3 Alkalosis pH = 0.008 x PCO2 HCO3 = -0.2 x PCO2 (usually not to less than 18 mEq/L) HCO3 = -0.4 x PCO2 (usually not to less than 18 mEq/L) PCO2 = 0.9(HCO3) + 9 +/-2 PCO2 = 0.6 x HCO3 ©MB and RR 2006, 2007 Revised 24April07 www.e-medtools.com œIndicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

Template updated 11/01/08