Pulmonary Consultation Note (Inpatient)

Date/Time of Service: [Date and time of encounter]

Patient Location: [Hospital name], [Unit/Room], [ICU / stepdown / floor]

Consulting Service: [Pulmonary / Critical Care / Pulmonary & Critical Care]

Requesting Clinician/Team: [Name and service]

Reason for Consult: [Specific consult question verbatim] (Capture the exact question when possible, e.g., "Hypoxemia on HFNC—etiology and management" or "Ventilator weaning guidance.")

One-Glance Summary

Brief Impression: [1–3 sentence synthesis of the current respiratory problem, phenotype (hypoxemic vs hypercapnic), suspected etiology, severity/trajectory, and response to therapy]

Recommendations:

• [Direct answer to the consult question as a clear action or conclusion]
• [Priority action #1: what to do, why, when, and target/endpoint] (Use action verbs; specify targets such as SpO₂ range, pH/PaCO₂ goals, ventilation parameters.)
• [Priority action #2: what to do, why, when, and target/endpoint]
• [Contingency plan with explicit escalation triggers and actions] (e.g., "If FiO₂ requirement increases above X% or pH < 7.25 despite NIV → obtain ABG and contact ICU for escalation evaluation.")

History

Respiratory Timeline:

[One-sentence framing of the chief pulmonary concern]

• Baseline status: [Home O₂ (flow), exertional tolerance, usual inhalers/PAP (settings), baseline CO₂ retention, prior intubations] (If unknown, document "Not documented.")
• Triggering event(s): [Event and timing]
• Trajectory: [Dated/time-stamped progression of symptoms and support requirements]
• Response to interventions: [Notable responses to oxygenation/ventilation, bronchodilators, diuresis, antibiotics, steroids, procedures]
• Current respiratory support and symptoms: [Device and exact settings; work of breathing; dyspnea/cough/pleurisy; sputum characteristics; hemoptysis] (Use direct patient quotes only if they clarify a key symptom.)

Pulmonary History: [COPD/asthma severity markers, ILD/bronchiectasis, pulmonary hypertension, prior pleural disease/pneumothorax, sleep-disordered breathing with PAP settings, prior TB/NTM/fungal disease] (Include only if present or suspected; otherwise state "None known.")

Relevant Comorbidities: [Concise list affecting pulmonary decisions: heart failure, CKD/ESRD, cirrhosis, immunocompromised state, neuromuscular disease, obesity hypoventilation, aspiration risk factors, bleeding risk] (Omit non-contributory items.)

Medications (pulmonary-relevant): [Bronchodilators; inhaled/systemic steroids (dose/duration); antibiotics; diuretics; sedatives/opioids; anticoagulants] (Note allergies with reaction types if they affect treatment decisions.)

Exposures: [Tobacco (pack-years); vaping; occupational/environmental; recent travel; sick contacts] (Include only if relevant to differential.)

Objective

Vitals and Respiratory Support:

• [Temp, HR, BP, RR, SpO₂] (Include clinically significant trends.)
• Oxygen/ventilation device and settings: [NC flow / HFNC flow & FiO₂ / NIV mode with IPAP-EPAP-FiO₂ / Invasive ventilation: mode, VT or pressure, RR, PEEP, FiO₂]
• Work of breathing: [Accessory muscle use, retractions, speaking in full sentences, paradoxical breathing]

Physical Exam:

• General: [Appearance, distress level]
• Pulmonary: [Air movement, wheeze, crackles, rhonchi, asymmetry, egophony, percussion]
• Cardiovascular: [Rate/rhythm, JVP, edema, perfusion]
• Volume status: [Dry / euvolemic / overloaded; supporting findings]
• Mental status: [Alertness, orientation, somnolence] (Note signs of hypercapnia when present.)

(Document today's findings only; do not copy forward prior exams.)

Key Data Review:

• Blood gases: [ABG/VBG values with date/time and oxygen/vent settings at draw] (If none, state "None available" and cite alternate data such as serum HCO₃⁻.)
• Labs: [CBC, HCO₃⁻, lactate, BNP/troponin, procalcitonin as pertinent, with dates]
• Microbiology: [Respiratory viral PCR; sputum/blood cultures; urine antigens with status and dates]
• Imaging: [CXR and CT chest with dates and key findings] (State "personally reviewed" vs "per radiology report"; include bedside ultrasound if performed.)
• Prior PFTs: [Pattern (obstructive/restrictive), FEV1/FVC, DLCO, date] (If none, state "None available.")
• Echo/EKG: [Findings relevant to cardiogenic process or RV strain with dates] (Include only if relevant.)
• Prior procedures: [Thoracentesis data, bronchoscopy results, prior intubation/vent course this admission with dates] (Include only if relevant.)

Assessment

[1–3 sentence synthesis integrating phenotype, severity, suspected etiology, response to therapy, trajectory, and key risks]

1. [Problem 1: Precise clinical label]

   [1–2 lines of supporting rationale with key evidence]

   [Differential diagnosis if uncertainty remains and affects management; label inferences as "likely" or "possible"]

2. [Problem 2: Precise clinical label]

   [1–2 lines of supporting rationale]

3. [Additional problems as relevant]

Plan

(Organize by problem. Be specific; limit to actionable recommendations.)

[Problem 1]

• Diagnostics: [Specific tests/studies with timing]
• Therapeutics: [Medications with dose/route/frequency; oxygenation/ventilation settings and targets; procedures]
• Monitoring and Targets: [Parameters to follow, frequency, and goals (SpO₂ range, pH, PaCO₂, RR)]
• Contingency/Escalation: [Explicit triggers and actions; include who to contact]

[Problem 2]

• Diagnostics: [As applicable]
• Therapeutics: [As applicable]
• Monitoring and Targets: [As applicable]
• Contingency/Escalation: [As applicable]

Communication

[Who was updated (name/role), what was discussed (key recommendations, urgent actions, escalation triggers), and when] (If recommendations were documented in chart only without verbal discussion, state this explicitly.)

Signature

[Clinician name], [Credentials] — [Role/Service]

[Contact information / pager]