Patient Label

PORT CF DATA

Visit date:______- Clinic Hospital Home IVs

Height:______ cm inWeight:______ kg lbs

Seen by Social Worker Seen by Dietician Seen by Respiratory Therapy

Laboratory
CBC CMP Hgb A1C OGTT GGT Fecal elastase
Microbiology Sputum culture done
GI/NUTRITION
Assessment of oral intake
No Yes, Is patient currently supplementation?
Oral supplementation Nasogastric tube (NG) Gastromy tube/button(G-tube)
Jejunal tube(J-tube) Total parental nutrition(TPN)
Salt supplement Yes NoCF SPECIFIC VITAMINS Yes No
Medications No change to medications
TOBI 300 mg BID QOM 300 mg continuous Other______
Other inhaled aminoglycides QOM Continuous Other______
(gentamicin, amikacin, other tobramycin preps)
Colistin 150 mg BID QOM Continuous Other______
Cayston 75mg TID Alternation months
TID continuous______Other______
Azithromycin Biaxin
Other chronic antibiotic: Quinolone (cipro, levoquin,etc)
Cephalsporin(cephalexin, keflex, cefiximine,etc)
Sulfa (bactrim) Amoxicillin (augmentin)
Tetracyline (doxycycline, vibramcyin, minocycline) Other:______
Pulmozyme 2.5 mg BID 2.5 mg daily other:______
Acetylcysteine or Mucomist
High dose ibuprofen (e.g. 25-30 mg/kg) Total mg/kg dose______
Hypertonic saline Concentration: 7%Other: ______
daily BID other regime
Oral Bronchodilators
Beta agnoist (proventil repetabs, volmax,etc) Theophylline (theodur, slo-bid, uniphyl,etc)
Inhaled bronchodilator
Short acting beta (albuterol, proventil, ventolin, xopenex, etc)
Long acting beta (salmeterol, serovent, foradil, bronvana, etc)
Short acting anticholinergic (Atrovent, ipratroprium)
Long acting anticholinergic (tiotroprium, spiriva)
Combination beta agonist and anticholnergic (combivent, duoneb, etc)
Corticosteroids
Oral (eg.prednisone) Inhaled (fluticasone, flovent, budesonide, pulmicort,etc)
Inhaleld combination w/bronchodilator (advair, symbicort, etc)
Other:
Leukotriene modifiers (montelukast, singulair, zafirlukast, accolade, zileuton, zyflow,etc)
Mast cell stabilizer (cromyln, intal, nedocromil tilade, etc)
Antifungals (itraconazole, sporanox)
Drug intolerance/allergies
Dornase alfa Tobramycin solution for inhalation Aztreonam Colistin
Macrolide antibiotics High dose ibuprofen Hypertonic saline
Enzymes
Creon ______# capsules w/ largest meal _____ total # capsule/day
PancreaseMT ______# capsules w/ largest meal _____ total # capsule/day
Ultrase MT______# capsules w/ largest meal _____ total # capsule/day
Pancrecarb MS______# capsules w/ largest meal _____ total # capsule/day
Zenpep______# capsules w/ largest meal _____ total # capsule/day
Specify other enzyme: ______# capsules w/ largest meal ____ total # capsule/day
Acid blockers
H2 blocker(zantac, pepcid) Proton pump inhibitor (acidphex, prevacid, protonix, nexium.priloc)
Unknown
Ursodeoxycholic acid
ACT/Exercise
Primary airway clearance technique
Postural drainage with clapping (CPT) Oscillating PEP (flutter, acapella, IPV)
Forced expiratory technique (autogenic drainage, huff cough, active cycle breathing
High frequency chest wall oscillation (vest) Exercise None
Secondary airway clearance technique
Postural drainage with clapping (CPT) Oscillating PEP (flutter, acapella, IPV)
Forced expiratory technique (autogenic drainage, huff cough, active cycle breathing
High frequency chest wall oscillation (vest) Exercise
Complications Listed in Port CF
CFRD Status No complications
Impaired Glucose Tolerance (FBG < 126, 2-h PG 140-199)
CFRD with or without fasting hyperglycemia
CFRD secondary complications
RetinopathyChronic renal insufficiencyMicroalbuminuria
Peripheral neuropathyChronic renal failure requiring dialysis
Hepatobiliary
Gall stonesGall stones, requiring surgery/procedure
Liver disease, cirrhosis. Please specify complications related to cirrhosis:
Esophageal varicesGastric varicesSplenomegaly
GI bleed related to varicesAscitesHepatic Steatosis
Liver disease, non- cirrhosisHypersplenism (i.e., WBC <3.0 or platelets <100,000)
Liver disease, other:______
Bone/Joints
Arthritis/ArthropathyBone fractureOsteopeniaOsteoporosis
Pulmonary
AsthmaHemoptysis,> 50 mlPneumothorax requiring chest tube
ABPA
GI
DIOS or Meconium ileus equiv.GI Bleed req hosp non variceal
Fibrosing colonopathy/colonic stricture (report incidence only)
GERDPancreatitisPeptic ulcer diseaseRectal prolapsed
Other Complications
Anxiety DisorderDepression
Hearing lossNasal polyps requiring surgerySinus Disease (symptomatic)
HypertensionAbsence of Vas DeferensKidney Stones
Renal failure requiring dialysis (cause other than CFRD)Cancer confirmed by histology
Complications not listed above______
PFTS
Unable use testReasons why PFTS not done:______
FVC measure (L)_____.__FEV1 measure(L)_____.___FEF 25-75 measure(L)_____.___
Symptoms
Yes NoWere there any new rales?
Assessment of Pulmonary exacerbation
Absent Mild exacerbation Moderate exacerbation Severe exacerbation
Mild, Moderate or Severe Treatment for exacerbation
Increased airway clearance, exercise, and/or bronchodilator
Oral NON-quinolones (azithromycin, bactrim, augmentin,etc
Oral quinolones (ciprofloxacin, levofloxacin)
Inhaled antibiotic
Inhaled antibiotic plus oral non-quinolone antibiotic
None of the above, specify______