Respiratory Physician Template

Respiratory Physician's note (custom)

A professional Respiratory Physician template for healthcare professionals.

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Specialty

Respiratory Physician

Used

20 times

Type

Note

Last edited

7/8/2025

Created by

M B Niazi

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About this template

Need to document a respiratory consultation? This Respiratory Physician's note template is designed for pulmonologists and respiratory specialists. It helps structure detailed patient information, including the reason for the visit, medical history, review of systems, examination findings, investigations, and a clear impression and plan. With Heidi, this template can be quickly populated from a medical visit transcript, ensuring comprehensive and accurate documentation. This template is perfect for creating detailed medical progress notes.

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- Reason for Visit: Shortness of breath and cough. - History of Presenting Illness: The patient is a 65-year-old male presenting with a two-week history of worsening shortness of breath, especially on exertion. He also reports a persistent cough, productive of clear sputum. He denies any fever, chest pain, or wheezing. - Past Medical History: The patient has a history of COPD, hypertension, and hyperlipidemia. - Current Medications: The patient is currently taking Salbutamol inhaler as needed, Ipratropium bromide inhaler twice daily, Lisinopril 20mg daily, and Atorvastatin 40mg daily. - Allergies: No known drug allergies. - Social History: The patient is a former smoker, having quit 5 years ago. He drinks alcohol occasionally. He denies any illicit drug use. - Family History: Father had a history of lung cancer. Mother has hypertension. Review of Systems: - Constitutional symptoms: Denies weight change, fever, chills, night sweats, fatigue, or malaise. - Eyes: Denies any eye symptoms. - Ears, Nose, Mouth, Throat: Denies any ENT symptoms. - Cardiovascular: Denies chest pain, orthopnea, or palpitations. - Respiratory: Reports cough and shortness of breath. - Gastrointestinal: Denies any gastrointestinal symptoms. - Genitourinary: Denies any genitourinary symptoms. - Musculoskeletal: Denies any musculoskeletal symptoms. - Integumentary (Skin): Denies any skin symptoms. - Neurological: Denies any neurological symptoms. - Psychiatric: Denies any psychiatric symptoms. - Endocrine: Denies any endocrine symptoms. - Hematologic/Lymphatic: Denies any hematologic/lymphatic symptoms. - Allergic/Immunologic: Denies any allergic/immunologic symptoms. Examination: - General: The patient appears to be in mild respiratory distress. Oxygen saturation is 92% on room air. - Respiratory: Chest auscultation reveals decreased air entry bilaterally with scattered wheezes. Investigations: - Chest X-ray performed on 1 November 2024 showed hyperinflation and mild interstitial changes. - Spirometry performed on 1 November 2024 showed an FEV1 of 55% predicted. Impression & Plan: 1. Issue, problem, or request 1 (issue, request, or condition name only): COPD exacerbation - Impression: COPD exacerbation. - Differential diagnosis: Pneumonia, pulmonary embolism. - Investigations planned: Repeat chest X-ray, arterial blood gas (ABG). - Treatment planned: Increase Salbutamol inhaler to every 4 hours, Prednisolone 40mg daily for 5 days, and consider antibiotics if there is evidence of infection. - Relevant referrals: Refer to respiratory physiotherapy. 2. Issue, problem, or request 2 (issue, request, or condition name only): Hypertension - Impression: Hypertension, well-controlled. - Differential diagnosis: Secondary hypertension. - Investigations planned: Routine blood tests. - Treatment planned: Continue Lisinopril 20mg daily. - Relevant referrals: No referrals needed. 3. Additional issues, problems, or requests: Hyperlipidemia - Impression: Hyperlipidemia, well-controlled. - Differential diagnosis: Familial hypercholesterolemia. - Investigations planned: Lipid panel. - Treatment planned: Continue Atorvastatin 40mg daily. - Relevant referrals: No referrals needed.