MedicalTemplates has developed a Pleural Effusion evaluation medical note template. This template is suitable for any health care provider who may evaluate a patient with pleural effusions.

What is a pleural effusion?

A pleural effusion is a collection of excess fluid in the pleural space which is between the lungs and the chest wall. Chest pain and difficulty breathing are the most common symptoms.

Pleural effusions are concerning because they can indicate the presence of malignancies, such as lung cancer, lymphoma, metastatic cancer, or rarely, mesothelioma. Fortunately, the most common causes of pleural effusions are a wide range of treatable medical conditions such as congestive heart failure (CHF), pneumonia, pancreatitis, lupus, kidney disease, liver disease, tuberculosis, and others. Because so many medical conditions can be associated with pleural effusions, it can be difficult to positively determine the etiology.

Determining the cause of the pleural effusion requires a detailed medical and occupational history that includes outside interests, such as hobbies, and a complete physical exam. All new pleural effusions of substantial volume must be evaluated by a thoracentesis. This is done by inserting a needle or tube into the pleural fluid, and sending the fluid for laboratory analysis. Laboratory analysis includes evaluation of the presence of bacteria, inflammatory cells, cancer cells, proteins indicative of tuberculosis, esophageal rupture or urinothorax, or antibodies indicative of autoimmune disease.

The pleural effusion evaluation medical template provides historical and laboratory prompters for the physician, facilitating a thorough and efficient investigation. Much of the documentation is done by clicking on checkboxes. Text boxes are provided to facilitate individualized documentation of the history, physical exam and impression and plan.