Pulmonary Arterial Hypertension Evaluation
Pulmonary Arterial Hypertension Evaluation
Pulmonary Arterial Hypertension Evaluation
Weight
BMI
GeneralAlert
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
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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
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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 directives47 Code Status Full code Do Not Attempt Resuscitation
Health Care Power Of Attorney is