Pulmonology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary respiratory concern]
Duration: [X] days/weeks/months/years
Current status: Improving / Stable / Worsening / Fluctuating

History of Present Illness

Dyspnea Assessment

Onset: Acute / Gradual / Chronic
Timing: At rest / Exertional / Nocturnal / Positional
Progression: Stable / Progressive / Fluctuating
mMRC Dyspnea Scale: [0-4]

• 0: Only with strenuous exercise
• 1: Hurrying or slight hill
• 2: Walks slower than peers or stops for breath
• 3: Stops after 100 yards or few minutes
• 4: Breathless dressing or leaving house

Triggers: Exertion / Allergens / Cold air / Irritants / Supine position / [Other]
Associated: Cough / Wheeze / Chest tightness / Orthopnea / PND / Edema / Chest pain
Exercise tolerance: [Flights of stairs, blocks walked, specific activities]
Baseline oxygen: None / [L/min, continuous vs exertional]

Cough Evaluation

Duration: Acute (<3 wk) / Subacute (3-8 wk) / Chronic (>8 wk)
Character: Dry / Productive
Timing: Constant / Intermittent / Nocturnal / Morning / Postnasal
Triggers: [Exercise, cold air, irritants, eating, talking]
Sputum: None / [Color, consistency, amount, blood]

• Daily volume: [Teaspoons, tablespoons, cups]
• Blood: None / Streaks / [Amount]

Associated: Dyspnea / Wheeze / Chest pain / Fever / Weight loss
Prior evaluation: [Treatments tried, imaging]

Wheeze/Asthma Symptoms

Wheezing: Yes / No — [Frequency]
Chest tightness: Yes / No — [Timing]
Nocturnal symptoms: Yes / No — [Frequency per month]
Rescue inhaler use: [Times per week]
Symptom triggers: [Allergens, exercise, cold, irritants, infections]
Seasonal variation: Yes / No — [Pattern]
Occupational variation: Yes / No — [Worse at work, better on vacation]
Exercise-induced: Yes / No
Aspirin sensitivity: Yes / No

Sleep-Related Symptoms

Snoring: None / Mild / Moderate / Severe
Witnessed apneas: Yes / No
Daytime sleepiness: [Epworth score X/24]
Morning headaches: Yes / No
Nocturia: [Times per night]
Sleep quality: Good / Fair / Poor
Sleep duration: [X] hours
Prior sleep study: No / Yes — [Date, AHI, treatment]
CPAP use: No / Yes — [Compliance, pressure, mask type]

Hemoptysis (if applicable)

Volume: Streaks / Teaspoons / [Larger amount]
Color: Bright red / Dark / Pink/frothy
Duration: [X] days
Frequency: [Episodes]
Associated: Cough / Dyspnea / Chest pain / Fever / Weight loss
Risk factors: Smoking / TB exposure / Anticoagulation / Malignancy history

Respiratory History

Known pulmonary diagnoses:

• Asthma: No / Yes — [Severity, age onset, control]
• COPD: No / Yes — [GOLD stage, FEV1, exacerbation history]
• ILD: No / Yes — [Type, date diagnosed]
• Bronchiectasis: No / Yes — [Etiology]
• Pulmonary hypertension: No / Yes — [Group, treatment]
• OSA: No / Yes — [AHI, on CPAP]
• Lung cancer: No / Yes — [Type, stage, treatment]
• PE/DVT: No / Yes — [Date, treatment]
• Pneumonia: No / Yes — [Frequency, last episode]
• TB: No / Yes — [Active vs latent, treatment]

Hospitalizations for respiratory: None / [Date, reason]
ICU/intubation: None / [Date, reason]
Prior pulmonary procedures: [Bronchoscopy, thoracentesis, biopsy]

Smoking History

Current smoking: No / Yes — [Cigarettes per day]
Former smoker: No / Yes — [Quit date]
Pack-years: [X]
Vaping/e-cigarettes: No / Yes — [Duration]
Secondhand smoke exposure: No / Yes — [Duration, setting]
Marijuana: No / Yes — [Frequency]
Other inhaled substances: No / Yes — [Type]

Occupational/Environmental History

Occupation: [Current and past]
Exposures:

• Asbestos: No / Yes — [Duration, type]
• Silica: No / Yes — [Duration]
• Coal dust: No / Yes — [Duration]
• Organic dusts: No / Yes — [Type]
• Chemicals/fumes: No / Yes — [Type]
• Mold: No / Yes — [Setting]
• Birds/feathers: No / Yes — [Type, duration]

Home environment:

• Pets: No / Yes — [Type]
• Carpeting: Yes / No
• Humidity issues: No / Yes
• Heating/cooling: [Type]
• Geographic: [Region, elevation]

Allergies and Immunizations

Drug allergies: [Medications and reactions]
Environmental allergies: [Seasonal, perennial, specific allergens]
Allergic rhinitis: No / Yes — [Treatment]
Eczema/atopic dermatitis: No / Yes
Immunizations:

• Influenza: [Date]
• Pneumococcal: PPSV23 [Date] / PCV13/15/20 [Date]
• COVID-19: [Date, type]
• Tdap: [Date]

Past Medical History

[Relevant conditions, especially:]

• Heart failure: No / Yes — [Type, EF]
• CAD: No / Yes — [History]
• Arrhythmias: No / Yes — [Type]
• GERD: No / Yes — [Treatment]
• Connective tissue disease: No / Yes — [Type]
• Obesity: BMI [X]
• Anxiety/panic: No / Yes
• Immunocompromised: No / Yes — [Reason]

Surgical History

[Relevant surgeries, especially:]

• Thoracic surgery: No / Yes — [Procedure, date]
• Cardiac surgery: No / Yes — [Procedure, date]
• Abdominal surgery: No / Yes — [Procedure]

Medications

Current respiratory medications:

• ICS: [Drug, dose, device]
• LABA: [Drug, dose]
• LAMA: [Drug, dose]
• ICS/LABA: [Drug, dose]
• Triple therapy: [Drug, dose]
• SABA: [Drug, frequency]
• SAMA: [Drug, frequency]
• Oral steroids: [Dose, duration]
• Biologics: [Drug, dose, frequency]
• Antifibrotics: [Drug, dose]
• PAH therapy: [Drugs]
• Oxygen: [L/min, hours/day]

Other medications: [List]

Family History

Asthma: No / Yes — [Relationship]
COPD: No / Yes — [Relationship]
Lung cancer: No / Yes — [Relationship, smoking]
Pulmonary fibrosis: No / Yes — [Relationship]
Alpha-1 antitrypsin deficiency: No / Yes
Cystic fibrosis: No / Yes
Other respiratory: [Details]

Social History

Tobacco: [As above]
Alcohol: [Quantity, frequency]
Living situation: [Home type, floors, others in home]
Occupation: [Current, exposures]
Exercise capacity: [Current ability]
Caregiver support: [Available, needed]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
SpO2: [X]% on [RA / O2 at X L]
Weight: [X] — BMI: [X]

General

Appearance: Well / [Cachectic, obese, in distress]
Respiratory distress: None / Mild / Moderate / Severe
Body habitus: Normal / Barrel chest / Kyphosis
Accessory muscle use: Absent / Present
Pursed-lip breathing: Absent / Present

HEENT

Nasal: Patent / Congested / Polyps / Deviation
Turbinates: Normal / Boggy / Hypertrophied
Oropharynx: Clear / Posterior drip / Cobblestoning
Mallampati: [I/II/III/IV]
Neck circumference: [X] cm (if OSA concern)

Neck

JVD: Absent / Present — [cm above sternal angle]
Lymphadenopathy: Absent / Present
Trachea: Midline / Deviated

Cardiovascular

Rhythm: Regular / Irregular
Heart sounds: Normal / [S3, S4, murmur, loud P2]
Peripheral pulses: [Assessment]
Edema: None / [Grade, distribution]

Pulmonary

Inspection:

• Chest wall: Symmetric / Asymmetric
• Deformity: None / [Pectus, kyphoscoliosis]
• Expansion: Symmetric / Asymmetric

Palpation:

• Tactile fremitus: Normal / [Increased, decreased]
• Chest wall tenderness: Absent / Present

Percussion:

• Resonance: Normal / Hyperresonant / Dull [Location]
• Diaphragmatic excursion: Normal / Diminished

Auscultation:

• Breath sounds: Normal / Diminished [Location] / Absent [Location]
• Air entry: Good / Reduced [Location]
• Adventitious sounds:
• Wheezes: Absent / Present — [Expiratory, inspiratory, location]
• Rhonchi: Absent / Present
• Crackles: Absent / Present — [Fine, coarse, location, timing]
• Stridor: Absent / Present
• Pleural rub: Absent / Present

Forced expiratory time: [X] seconds (normal <6 sec)

Extremities

Clubbing: Absent / Present
Cyanosis: Absent / Present — [Central, peripheral]
Edema: Absent / Present — [Grade]

Skin

Rash: Absent / Present — [Description]
Nicotine staining: Absent / Present

Pulmonary Function Tests

Spirometry [Date]

FVC: [X] L ([X]% predicted)
FEV1: [X] L ([X]% predicted)
FEV1/FVC: [X]% (LLN: [X]%)
Pattern: Normal / Obstructive / Restrictive / Mixed

Post-Bronchodilator

FEV1 change: [X] mL ([X]%)
Significant bronchodilator response: Yes (≥12% and ≥200 mL) / No

Lung Volumes [Date]

TLC: [X] L ([X]% predicted)
RV: [X] L ([X]% predicted)
RV/TLC: [X]%

Diffusion Capacity [Date]

DLCO: [X] ([X]% predicted)
DLCO/VA: [X] ([X]% predicted)

Interpretation

[Summary of PFT findings and clinical correlation]

Imaging Review

Chest X-ray [Date]

• Lung fields: Clear / [Infiltrates, nodules, masses]
• Heart size: Normal / Cardiomegaly
• Pleural: Normal / [Effusion, thickening]
• Other: [Findings]

CT Chest [Date]

• Parenchyma: Normal / [Emphysema, fibrosis, nodules]
• Airways: Normal / [Bronchiectasis, wall thickening]
• Nodules: None / [Size, location, characteristics]
• Lymph nodes: Normal / [Enlarged]
• Pleural: Normal / [Effusion, thickening]
• Other: [Findings]

Other Imaging

[PET, V/Q, echo if available]

Assessment

1) [Primary pulmonary diagnosis]
Severity: [Mild, moderate, severe]
Control: [Well-controlled, partially controlled, uncontrolled]
2) [Secondary diagnoses]
3) [Additional findings - nodule, etc.]

Plan

Diagnostic Workup

Pulmonary Function:

• [ ] Spirometry with bronchodilator
• [ ] Full PFTs with DLCO
• [ ] Methacholine challenge
• [ ] 6-minute walk test
• [ ] Cardiopulmonary exercise test

Imaging:

• [ ] Chest X-ray
• [ ] CT chest [High-resolution, with contrast]
• [ ] V/Q scan
• [ ] CT angiography

Laboratory:

• [ ] CBC, CMP
• [ ] BNP/NT-proBNP
• [ ] Alpha-1 antitrypsin level
• [ ] IgE, eosinophil count
• [ ] Autoimmune panel (if ILD concern)
• [ ] Sputum culture/cytology
• [ ] AFB smear/culture

Other:

• [ ] Sleep study (HST vs in-lab PSG)
• [ ] Bronchoscopy with BAL/biopsy
• [ ] Echocardiogram
• [ ] Right heart catheterization

Treatment

Pharmacotherapy:

• [New medications with dose and instructions]
• [Adjustments to current therapy]
• [Inhaler technique review]

Oxygen therapy:

• [ ] Home oxygen evaluation
• [ ] Ambulatory oxygen
• Current: [L/min, hours/day, equipment]

Non-pharmacological:

• [ ] Smoking cessation: [Counseling, NRT, medications]
• [ ] Pulmonary rehabilitation
• [ ] Vaccinations: [Flu, pneumococcal, COVID]
• [ ] Allergen avoidance
• [ ] Weight management

Referrals

• [ ] Pulmonary rehabilitation
• [ ] Thoracic surgery
• [ ] Interventional pulmonology
• [ ] Sleep medicine
• [ ] Allergy/immunology
• [ ] Cardiology
• [ ] Smoking cessation program

Patient Education

• Diagnosis explanation
• Medication/inhaler instructions
• Oxygen safety (if applicable)
• Action plan for exacerbations
• Warning signs requiring urgent evaluation
• Smoking cessation resources

Follow-up

Return: [X] weeks for [Results, response assessment]
Sooner if: [Worsening dyspnea, fever, hemoptysis, severe exacerbation]

Communication

Discussed with patient: [Topics covered]
Report sent to: [Referring physician, PCP]