ewrobbins.com

.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,
time: 
name:
NL4: 

RFV: 
Checks: 
  [] LDCT:
  [] PFTs:
  
Results pending:
  [] 
  
Next Steps:
  [] 

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|

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