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ummc:va:cprs_templates [2023/10/04 17:26] – adminummc:va:cprs_templates [2023/12/18 14:51] (current) – [Clinic Note] admin
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 +</code>
 +
 +=====Clinic Note =====
 +
 +<code>
 +Assessment / Plan
 +
 +@@-year-old with history of x, initially admitted for X, now with x.
 +
 +@@
 +
 +Recommendations
 +
 +- xxx
 +- xxx
 +
 +Subjective
 +
 +- 
 +
 +Environmental exposures:
 +[ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers
 +[ ] hot tub use
 +[ ] pets/ birds at home
 +[ ] playing any wind instruments
 +[ ] hobbies such as wood working
 +[ ] mold/water damage in the house
 +
 +Military-specific exposures:
 +[ ] Agent orange - Vietnam War
 +[ ] Depleted Uranium - Gulf War
 +[ ] Asbestos - Navy due to shipyards
 +[ ] Mustard gas – WWI
 +[ ] Particulate matter
 +[ ] Burn pit
 +[ ] Chromium
 +
 +Occupational exposures outside the military :
 +[ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters
 +[ ] Ionizing radiation - uranium mining
 +[ ] Vinyl chloride - pulp & paper workers
 +[ ] Arsenic - smelting of ores, pesticide application, wood preservation
 +[ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers
 +[ ] chromium - stainless steel production, welding, tanning industries
 +[ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters
 +
 +PMH:
 +|ACTIVE PROBLEMS|
 +
 +Medications:
 +|ACTIVE MEDICATIONS|
 +
 +Allergies:
 +|ALLERGIES/ADR|
 +|999Y1 PNEUMO|
 +|999Y1 FLU,WHOLE|
 +
 +SH:
 +Functional status: @@
 +[ ] fully independent in ADLs and IADLs
 +[ ] uses cane at baseline
 +[ ] uses walker at baseline
 +[ ] uses wheelchair at baseline
 +[ ] uses oxygen at baseline
 +
 +[ ] Tobacco Smoking –
 +Age of onset of smoking: years
 +Duration of smoking: years
 +Maximum packs/day:
 +Current cigarettes /day:
 +
 +Any alternate tobacco product
 +[ ] cigar,
 +[ ] pipe,
 +[ ] waterpipe
 +[ ] Vape/e cigarettes
 +[ ] Second hand smoking
 +[ ] Indoor emission from household combustion
 +[ ] Outdoor air pollution
 +
 +
 +ROS:
 +Constitutional: No fevers, chills, sweats, weight change, or fatigue
 +Eyes: No itchy, watery eyes, no blurry vision
 +ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip
 +Skin: No Rash
 +CV: No chest pain, palpitations, PND, orthopnea
 +Respiratory: As above.
 +GI: No heartburn
 +MSK: No joint pains/myalgias
 +Neuro: No numbness/tingling
 +
 +Objective
 +
 +Vitals:
 +|VITALS|
 +
 +Exam: 
 +General: NAD, alert, WD, WN
 +Eyes: PERRL, no scleral icterus
 +ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@
 +Skin: warm, intact, no rashes
 +Neck: ROM and lymph node assessment
 +LN: axillary, supra-clavicular, and inguinal lymph node assessment
 +CV: RRR, no MRG, nl S1 and S2, no peripheral edema
 +Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis
 +Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly
 +Neuro: Awake alert oriented to person place time and situation
 +
 +Labs & Imaging: All labs and imaging within past 24 hr personally reviewed by me.
 +|PFT |
 +|CHEST 2 VIEWS PA&LAT|
 +|CHEST CT|
 +
 +
 +</code>
 +
 +=====Clinic, Lung Mass=====
 +<code>
 +Lung Mass Consult:
 +
 +Reason for Referral: Nodule / Mass in
 +
 +HPI:
 +
 +Environmental exposures:
 +[ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers
 +[ ] hot tub use
 +[ ] pets/ birds at home
 +[ ] playing any wind instruments
 +[ ] hobbies such as wood working
 +[ ] mold/water damage in the house
 +
 +PMH:
 +|ACTIVE PROBLEMS|
 +
 +Medications:
 +|ACTIVE MEDICATIONS|
 +
 +Allergies:
 +|ALLERGIES/ADR|
 +|999Y1 PNEUMO|
 +|999Y1 FLU,WHOLE|
 +
 +SH:
 +[ ] Tobacco Smoking –
 +Age of onset of smoking: years
 +Duration of smoking: years
 +Maximum packs/day:
 +Current cigarettes /day:
 +
 +Any alternate tobacco product
 +[ ] cigar,
 +[ ] pipe,
 +[ ] waterpipe
 +[ ] Vape/e cigarettes
 +[ ] Second hand smoking
 +[ ] Indoor emission from household combustion
 +[ ] Outdoor air pollution
 +
 +Military-specific exposures:
 +[ ] Agent orange - Vietnam War
 +[ ] Depleted Uranium - Gulf War
 +[ ] Asbestos - Navy due to shipyards
 +[ ] Mustard gas – WWI
 +[ ] Particulate matter
 +[ ] Burn pit
 +[ ] Chromium
 +
 +Occupational exposures outside the military :
 +[ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters
 +[ ] Ionizing radiation - uranium mining
 +[ ] Vinyl chloride - pulp & paper workers
 +[ ] Arsenic - smelting of ores, pesticide application, wood preservation
 +[ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers
 +[ ] chromium - stainless steel production, welding, tanning industries
 +[ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters
 +
 +FH:
 +[ ] Relatives with hx of lung cancer
 +[ ] Relatives with other types of cancer
 +[ ] Family history of lung disease:
 +
 +STOP-BANG Score:
 +[ ] Snoring - do you snore loudly?
 +[ ] Tired - do you feel tired, fatigued, or sleepy during daytime?
 +[ ] Observed apneas?
 +[ ] Pressure - hx of high blood pressure?
 +[ ] BMI?
 +[ ] Age > 50?
 +[ ] Neck circumference: > 16 inch or 40 cm collar?
 +[ ] Male Gender
 +
 +Hx of Anesthesia reactions:
 +[ ] Prior surgeries and anesthesia reactions
 +[ ] Hx of difficult intubation
 +[ ] Family Hx of malignant hyperthermia
 +
 +ROS:
 +Constitutional: No fevers, chills, sweats, weight change, or fatigue
 +Eyes: No itchy, watery eyes, no blurry vision
 +ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip
 +Skin: No Rash
 +CV: No chest pain, palpitations, PND, orthopnea
 +Respiratory: As above.
 +GI: No heartburn
 +MSK: No joint pains/myalgias
 +Neuro: No numbness/tingling
 +
 +Exam:
 +
 +VS:
 +|VITALS|
 +
 +General: NAD, alert, WD, WN
 +Eyes: PERRL, no scleral icterus
 +ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@
 +Skin: warm, intact, no rashes
 +Neck: ROM and lymph node assessment
 +LN: axillary, supra-clavicular, and inguinal lymph node assessment
 +CV: RRR, no MRG, nl S1 and S2, no peripheral edema
 +Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis
 +Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly
 +Neuro: Awake alert oriented to person place time and situation
 +
 +Data:
 +
 +|PFT |
 +|CHEST 2 VIEWS PA&LAT|
 +|CHEST CT|
 +
 +https://www.mdcalc.com/calc/3910/duke-activity-status-index-dasi
 +
 +ASA grade:
 +[ ] ASA I - normal healthy patient
 +[ ] ASA II - a patient with mild systemic disease
 +[ ] ASA III - a patient with severe systemic disease
 +[ ] ASA IV - a patient with severe systemic disease that is a constant threat to life
 +
 +Karnofsky Performance Status Scale (mdcalc.com)
 +
 +Assessment: Solitary Pulmonary Nodule Malignancy Risk (medscape.com)
 +
 +Plan:
 +
 +I discussed the above plan with the attending, Dr. Janaki Deepak.
 +
 +IP attending Dr. was also present to staff this patient
 </code> </code>
ummc/va/cprs_templates.1696440402.txt.gz · Last modified: 2023/10/04 17:26 by admin

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