1. health and fitness
2. disease

HOW TO FILL PROFORMA VERSION 6
ILD- India Registry: Indian Chest Society (Proforma Version 6)
Center code
Date: …………………..…
Email ……….…………………………
Name of the Consultant ……………………….
Mobile no. ……………..……………..
Address for correspondence …………………….…………………….………………………………….
Particulars of the patients
Patient Code number
Age and sex
Date of the birth
Name and address of the patient will not be disclosed. The data of name and address will be noted in the
investigators patient’s log. It will also be stored in the website and will be used by a computer program to
stop enrolment of a single patient two times from the same center or from other center. The identity of the
patient will not be revealed. Every patient will be give a code number.
Patient code number : The code number of the patient will be given by the recruiting center by putting
numerical number after center code number. If center code is AC then patient number may be AC 1,
AC2, AC3 …
Inclusion: Patients presenting with following
Yes
No
Respiratory symptoms such as shortness of breath and cough
Bilateral abnormalities in X ray/HRCT scan thorax
No
Yes
Exclusion:
Any Infectious or Malignant diseases
Yes
No
On basis of inclusion and exclusion criteria a patient suspected to have ILD can be identified and
thereafter workup of the patient can be done as follows:
Proforma questionnaire based on patient’s history
1. Symptoms of patient
Symptom
Since when
Any comment
a) Cough
March 2007
Every day, dry
b) Dyspnoea
Jan 2008
Grade 2
c) ______________________________________________________________________________
d) ______________________________________________________________________________
e) ______________________________________________________________________________
f) _______________________________________________________________________________
g) ______________________________________________________________________________
Please put all the symptoms (related or unrelated) in chronological order. Instead of duration it is better
to write year of onset.
Cough: Frequency ? (Do not include clearing of throat.)None (at all)/Rarely/Everyday/ Severe
attacks that interfere with activity
Dry (No expectoration)/Mucoid/Yellow-green/Green /Blood tinged/Blood
Shortness of breath: Check the single number that describe the point at which S/he becomes
short of breath:
0. Not troubled with breathlessness except with strenuous exercise
1. Short of breath when hurrying on the level or walking up a slight hill.
2. Walks slower than people of her/his age on the level because of breathlessness
or S/he has to stop from breath when walking on normal pace on the level.
3. Stops for breath after walking about 100 yards or after a few minutes on the level.
4. Too breathless to leave the house or breathless on dressing or undressing.
2. Has the patient noticed any of the following? (put  in respective column)
Yes No Duration &
Yes
Remarks
a) Weight loss
b) Difficulty in
swallowing
No
Duration &
Remarks
g) Bruising
skin
h) Hand ulcers
c) Dry eyes or dry mouth
i)
Mouth
ulcers
Chest pain
d) Rash or changes in
skin
j)
e) Oedema on legs
k) Joint pain
f) Blood in urine
l) Symptoms of Gastro-oesophagial reflux (GERD) :
Yes
No
(If yes put )
i. Indigestion __________ ii. Heartburn __________ iii. Acid-sour taste ____ iv. Belching _
v. Bloating sensation ___ vi. Cough after meals ___ vii. Cough at night times/sleeping ___
Following symptoms may indicate, presence of below mentioned causes or results of ILD
a)Weight loss –Almost all symptomatic patients with ILD specially in Rheumatoid arthritis, SLE ,
Wegener’s granulomatosis, Tuberculosis, Cryptogenic organising pneumonia, Pulmonary Langerhans
cell histiocytosis, Malignancy, Allergic granulomatosis of Churg-Strauss.
b) Difficulty in swallowing- Esophageal Dysmotility in Systemic Sclerosis
c) Dry eyes or dry mouth- Sjogren’s syndrome, Sarcoidosis, Systemic Sclerosis
d) Rash or changes in skin- Connective tissue diseases like SLE, R A, Sarcoidosis, Wegener’s
granulomatosis,Raynaud’s phenomena, Behcet’s diasease; Maculopapular rash- drug induced, CTD,
amyloidosis, gaucher’s disease; Telangictasia: scleroderma; Cutaneous vasculitis; CTD
e) Oedema of legs- Congestive heart failure.
f) Blood in urine- Glomerulonephritis in Goodpasture’s syndrome, SLE, Wegener’s granulomatosis,
Sarcoidosis
g)Bruising skin –use of Steroid, vasculitis
h)Hand ulcers - Systemic sclerosis, Vasculitis
i) Mouth ulcers – SLE, Wegener’s granulomatosis , HIV, Behcet’s diasease
j) Chest pain –Pleuritis in Wegener’s granulomatosis ,SLE ,RA
k) Joint pain- Connective tissue disease like SLE ,RA , Ankylosing Spondylitis, Wegener’s
granulomatosis, Sjogren’s syndrome.
l) GERD – occurs in Systemic Sclerosis. Can be a cause of Aspiration pneumonia and chronic cough
3. Has any doctor ever told him (past or known medical history) (put  in respective column)
Never
a) Tuberculosis
b) Extra pulmonary
Tuberculosis
c) Hypertension
d) Diabetes
e) Coronary heart
disease
f) Heart failure
g) Thyroid disease
h) Stroke (CVA)
i) Seizure
j)
Hepatitis A/ B/C
k) Hapatitis,
other/unknown
l) Kidney disease
m) Anemia
n) Eye inflammation
o) Parasites (worms)
p) Pneumothorax
q) Pleural effusion
r) Pneumonia
s) Asthma
t) Bronchitis
u) Sinus disease
v) Pulmonary
hypertension
Before ILD
Treatment
After ILD
treatment
Never
w)Pulmonary
embolism
x) Sleep apnoea
y) Lung Cancer
z) GERD
aa) Hiatal hernia
ab) Bleeding disorder
ac) Rheumatologic
disease /collagen
vascular disease
ad) Vasculitis
ae) Raynaud’s
phenomenon
af) Rheumatoid
arthritis,
ag) Lupus
ah) Scleroderma
ai) Mixed connective
tissue disease
aj) Sjogren’s
Syndrome
ak) Wegener’s,
al) Polymyositis or
dermatomyositis
am) Bechet’s disease
an) Ankylosing
spondylitis.
ao) overlapping
ap) unspecified/
unclear
Others i)
ii)
Before
ILD
treatment
After ILD
treatment
Various diseases mentioned here are associated with specific type of ILD or starts with complication of
therapy of ILD. Therefore please go through the list carefully and indicate the onset of the disease before
initiation of treatment of ILD or after it. Common associations are as follows:
a) Tuberculosis- associated with bronchocentric granulomatosis. Can cause lung fibrosis and restrictive
pattern in PFT
b) Extra pulmonary Tuberculosis
c) Hypertension – occurs in Systemic Sclerosis, neurofibromatosis, diffuse alveolar hemorrage
d) Diabetes-Patients more prone to get tuberculosis, more severe pneumonia and thus complications.
Conversely steroids may precipitate diabetes.
e) Coronary heart disease-RA, SLE
f) Heart failure –Infiltrative diseases like Sarcoidosis , Systemic Sclerosis , Ankylosing Spondylitis,
Symptoms and CT picture ( in lying down position ) may mimic ILD.
g) Thyroid disease- Autoimmune diseases. Infiltrative disease like Systemic Sclerosis may cause
hypothyroidism as well as ILD
h) Stroke(CVA) – Vasculitis. Prone for Aspiration pneumonia
i) Seizures (Prone for Aspiration pneumonia) - Tuberous Sclerosis, Neurofibromatosis, Gaucher’s
disease. Prone for Aspiration pneumonia.
j)Hepatitis A/B/C –Chronic active hepatitis causes ILD
k) Hepatitis Other unknown
l) Kidney diseases-Amylodosis, Goodpasture’s syndrome, Wegener’s granulomatosis, Connective tissue
diseases,Sarcoidosis
m) Anaemia-Connective tissue diseases ,Gauchers Disease, Cytotoxic drugs like Cyclophosphamide used
in treatment of ILD
n) Eye inflammation - Sjogren’s syndrome, Wegener’s granulomatosis, Ankylosing Spondylitis,
sarcoidosis
o) Parasites –Eosinophilic Pneumonias
p) Pneumothorax- Systemic sclerosis, RA, Pulmonary Langerhans cell histiocytosis, Pulmonary
lymphangioleiomyomatosis.
q) Pleural effusion- SLE, RA, Tuberculosis, Pulmonary lymphangioleiomyomatosis.
r) Pneumonia- Acute interstitial pneumonia, ARDS.
s) Asthma- Eosinophilic pneumonia.
t) Bronchitis- Sjogren’s syndrome, inhalation of toxic fumes, organic dust.
u) Sinus disease- Wegener’s granulomatosis, Allergic granulomatosis of Churg-Strauss, Sarcoidosis.
v) Pulmonary Hypertension- SLE, RA, Systemic sclerosis, Sarcoidosis.
w) Pulmonary embolism- chronic PE causes pulmonary hypertension and presents as dyspnoea and
hypoxemia.
x) Sleep apnoea- causes hypoxemia and eventually pulmonary hypertension.
y) Lung cancer- Associated with Asbestosis, Inhalation of smoke of tobacco, polycyclic hydrocarbons,
biomass fuel
z) GERD- Systemic sclerosis, can cause aspiration pneumonia, common cause of chronic cough.
aa) Hiatal hernia-cause of GERD
ab) Bleeding disorder-Hermansky- Pudlak syndrome
ac) Rheumatologic diseases/ Collagen vascular disease - cause ILD
ad)Vasculitis- occurs in diaeases like wegener’s granulomatosis, allergic granulomatosis of Churg and
Strauss, SLE, RA, Sarcoidosis etc.
ae) Raynaud’s phenomena - Systemic sclerosis, SLE, RA, Dermatomyositis, polymyositis, IPF.
af) Rheumatoid arthritis,
ag) Lupus
ah) Scleroderma
ai) Mixed connective tissue disease
aj) Sjogren’s Syndrome
ak) Wegener’s
al) Polymyositis or dermatomyositis
am) Bechet’s disease
an) Ankylosing spondylitis.
ao) Overlapping
ap) Unspecified/ unclear
Others
Domestic environmental factors
Duration & Remarks
4. Conditions of his/her house
Yes
No
a) Dusts (visible) ----------------------------------------------------------------Yes
No
b) Molds(visible) ----------------------------------------------------------------Yes
No
c) Air conditioner --------------------------------------------------------------No
Yes
d) Cooler --------------------------------------------------------------------------No
Yes
e) Birds in home(caged) (Include pigeons, parrot, hen, crow mourning
No
dove)
Yes
f) Any changes in house/housing conditions in recent past ---------g) IF YES to changes in housing conditions, how many days,
months or years before the cough and/or breathing /chest problems ___________________
a) Dusts (visible) – organic dust :hypersensitivity pneumonitis like Bagassosis, Farmers lungs.
Inorganic dust like silica causes ILD
b) Molds(visible) – hypersensitivity pneumonitis
c) Air conditioner- hypersensitivity pneumonitis ( Air conditioner Lung)
d ) Cooler- hypersensitivity pneumonitis (Humidifier lung)
e) Birds- hypersensitivity pneumonitis(Birds fancier’s lung)
f) Changes in house/housing conditions may cause hypersensitivity pneumonitis due to molds
g) To classify them into acute, subacute and chronic hypersensitivity pneumonitis.
Duration & Remarks
5. Does the current or past home have/had following
Yes
No
a) Open cooking on fire wood or cow dung -----------------------------Yes
No
a) Cooking on kerosene stove -----------------------------------------------Yes
No
b) Cooking on coal -------------------------------------------------------------No
c) Cooking with LPG gas ----------------------------------------------------Yes
a) Open cooking on fire wood or cow dung-Fumes of acrolein and other aldehydes can cause mucosal
irritation and decrease in lung function. To look association with ILD
b) Acid fumes cause bronchitis.
c) Cooking on coal- inhalation of SO2,NO2, cause chronic bronchitis
d) Cooking with LPG gas- to know the frequency of LPG users
6. Previous residential locations (Please list all locations lived for atleast 6 months.)
Duration & Remarks
a) Urban (District headquarter or higher) ---------------------------Yes
No
b) Sub urban (Tehsil HQ) ------------------------------------------------------Yes
No
a) Rural-village (Panchayat HQ or lower) ---------------------------------Yes
No
Others _____________________________________________________________________________
People living in urban areas are more exposed to vehicular pollution while rural patients are more
exposed to molds and many other organic dusts.
7. Work environmental factors :
Working outside house
No
Yes
8. Occupational history: Please include all occupations worked : (include dust, metal, paint, fine
particles, etc) List any exposures that you feel might be related to cough/breathing /chest
problems and /or not listed above? (see appendix A)
Occupation
Years worked [from-to]
Exposures
_________________________
______________________
___________________
_________________________
______________________
___________________
_________________________
______________________
___________________
_________________________
______________________
___________________
_________________________
______________________
___________________
9. Exposed to visibly smoky or dusty air?
No
Yes
10. Use of protective masks while working
No
Yes
Work environmental factors: Any exposure to organic or inorganic dust should be mentioned. Duration
of exposure is important for ILD eg. Asbestosis develop after ten years of exposure and Coal Workers
Pneumoconiosis develops after 15 to 20 years of exposure. Stone workers are prone to develop silicosis
while pipe fitters may develop asbestosis. Hypersensitivity pneumonitis may develop in farmers and
carpenters.. Mask may protect from inhaling dust
11. Ever taken substance of abuse such as cannabis, opium or smoked ganza, charas etc?
12. Inhaled tobacco use? (If yes put ) Never
Current
Ever
Tobacco use:
Bidi
Cigarette
Hookah/
Chillum
Chewing
tobacco
Alcohol
Yes
Ganza, charas
Starting age
Stopping age
Quantity/Day
Opiates may cause lung fibrosis. Tobacco smoke may cause chronic bronchitis, fibrosis. 66% to 75% of
the IPF patients are smokers. Strong association of smoking is also present in PLCH, DIP, Goodpasture’s
syndrome, Respiratory bronchiolitis and pulmonary alveolar proteinosis.
No
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Name of medicines
patient has taken
in the PAST
Starting
date
Stopping
date
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
Medication history – Many drugs can cause ILD such as amiodarone, acyclovir, bleomycin,
busulphan, methotrexate, chlorambucil, melphalan, methysergide, nitrofurantoin, sulphonamides,
aminoglycosides, opiates, hypnotics, mitomycin C, gold, polymyxins. Drugs used in treatment of ILD can
also predispose many conditions such as diabetes, increased occurrence of infections etc.
13. b) How many courses of antibiotics were taken in last one year? _______________
14. Family medical history (biological): grandparents, parents, brothers, sisters, aunts,
uncles, first cousins, or children have any of the following lung disease?
Yes
a) Asthma --------------------------------------------------------------------------------Yes
b) Chronic Obstructive Pulmonary disease (COPD) -------------------------------Yes
c) Sarcoidosis ----------------------------------------------------------------------------Yes
b) Bronchiectasis ------------------------------------------------------------------------Yes
c) Pulmonary fibrosis (ILD/IPF) -----------------------------------------------------Yes
d) Hypersensitivity pneumonitis ----------------------------------------------------Yes
Relation
No
No
No
No
No
No
No
e) Rheumatologic disease /collagen vascular disease ( i. rheumatoid arthritis, ii. lupus, iii. scleroderma,
iv. mixed connective tissue disease, v. Sjogren’s Syndrome, vi. Wegener’s, vii. Polymyositis or
dermatomyositis , viii. Bechet’s disease, ix. Ankylosing spondylitis x. Overlapping
xi. Unspecified/unclear_
Asthma is genetically transmitted. Familial inheritance also exists in Sarcoidosis, rheumatological
diseases, Tuberous sclerosis, neurofibromatosis, Niemann-Pick disease, Gaucher’s disease, HermanskyPudlak syndrome. Familial lung fibrosis may present as different patterns of interstitial pneumonia.
Moreover, more than one family member can be affected if residing in close proximity to mines or other
areas of dust exposure.
Disease
Status
Route
Stopping
date
Dose
Starting
date
Route
Name of medicine
patient is taking
PRESENTLY
Dose
13. a) Medication history: Please include all medicines patient has taken especially those given
in Appendix E
15. Physical examination:
Pulse ___________ BP _________________ JVP ___________________ Cynosis _______________
Height __________ Weight ____________ BMI _____________________ Face/ Head_______
Eye/ ENT ____________ Skin __________________ Joints __________Clubbing ____________
Bibasillar crackles _______Wheeze _______________ P2 heart) _______ Pallor _______________
Icterus ________________ Lymphademopathy ____ Others
_________________________________
Physical examinationFace & skin- Rashes, ulcers in SLE, RA, Systemic sclerosis, Sjogren’s syndrome, Behcet’s disease,
Sarcoidosis. Prolonged intake of steroids causes moon facies and easy bruising on skin.
Joints – Arthritis and arthralgia in connective tissue diseases, Wegener’s granulomatosis, Sjogren’s
syndrome.
Clubbing-IPF, Primary biliary cirrhosis, Inflammatory bowel diseases.
Bibasillar crackles- most common auscultatory finding in ILD. May also occur in CHF.
Pallor- Connective tissue diseases, Gaucher’s disease, result of cytotoxic drugs.
Icterus- Hepatitis(infective or drug induced), cirrhosis.
Lymphadenopathy- Tuberculosis, HIV, Sarcoidosis, lymphoma, lymphocyatic interstitial pneumonia
Salivary gland enlarged: sarcoidosis, lymphocyatic interstitial pneumonia
Hepatosplenomegaly: Sarcoidosis,CTD, amyloidosis, lymphocyatic interstitial pneumonia
JVP- Cor pulmonale, CHF
16. Investigations (Pulmonary evaluation):
A. Spirometry, lung volumes and diffusing capacity (Indian predicted value)
Predicted
Actual
Percentage
Post
Reversibility%
FEV1
FVC
FEV1/FVC
PEFR
Total lung capacity
RV
DLCO (corrected for hb)
KCO
B. ABG (while breathing air at sea level ) pH _____ pO2 _____ pCO2 _____ HCO3 _____
C. 6 minute walk test: Test performed while breathing air
Yes
No
Test performed with supplemental Oxygen
If
Yes
No
Yes,……….l/min
Distance covered in 6 minutes _____ Baseline SpO2 _____ SpO2 immediately after walk …….
Reason for stopping before 6 minutes : breathless …….Fatigue….leg /joint pain ………..
Borg scale dyspnea : Rest ……… At the end of testing ……..
D. Fiberoptic Bronchoscopy (When relevant)
date_________
Yes
No
Fiberoptic Bronchoscopy Findings/diagnosis
f) Consistent with: alveolar hemorrhage……, proteinosis…,
Purulent secretions/infection… Others……….
ii) Smear for acid fast bacilli, cultures for M Tb /Myc species _____________
iii) Transbronchial biopsy: specific diagnosis - granuloma ____; malignancy _____infection
iv) Consistent with: Sarcoidosis .. Hypersensitivity pneumonitis …, Lymphangiectatic
carcinoma….
E. Open /surgical /thoracoscopic lung biopsy: (If performed)
Yes
No date _________
i)Right lung (upper lobe/middle lobe/lowerlobe) __________Left Lung(upper lobe
/lingula/lower lobe
ii) Pathology (surgical lung biopsy)
Date____________
Yes
No
UIP Consistent :
definite
probable
possible
definitely not
Per OFFICIAL DOCUMENT –ATS-ERS-JRS-ALAT (Raghu et al AJRCCM, March 15 2011)
F. Chest Xray Recent: bilateral shadows present
Chest Xray, old: bilateral shadows present
Yes
No
Yes
No
date _________
date _________
G. HRCT : 1mm cuts Yes
No ;Prone & supine views Yes
No , Expiratory views Yes
Report: Date of HRCT :
_____________________________________________________________________________________
_____________________________________________________________________________________
UIP:
Yes
No
High resolution computed tomography criteria for UIP pattern in
Appendix C.
Yes
No
H. Sinus CT (Optional) ___ SINUSITIS
INVESTIGATIONS
Spirometry and lung volumes- most common presentation in ILD is restrictive pattern with decreased
TLC, FRC and RV. FEV1 and FVC are also decreased but FEV1/FVC is normal or increased.
Obstructive pattern may also be seen particularly in LAM and Tuberous sclerosis. It also has prognostic
value in IPF and NSIP.
Diffusion capacity- reduced in ILD.
ABG- may be normal or may show hypoxemia and respiratory alkalosis particularly during exercise as
revealed after 6MWT.
Fiberoptic Bronchoscopy- Bronchoalveolar lavage(BAL) findingsPulmonary alveolar proteinosis: BAL yields a cloudy, effluent that contains large amounts of
periodic acid-Schiff–positive lipoproteinaceous material, as evidenced by light microscopy.
5% or more CD1a-positive cells in the BAL fluid is highly specific for the diagnosis of pulmonary
Langerhan’s cell histiocytosis.
BAL finding diagnose Pulmonary hemorrhage, berylliosis, hypersensitivity pneumonitis, and some
pneumoconioses. BAL cell profiles are not diagnostic in idiopathic interstitial pneumonias.
Excess of neutrophils: the proportions of which correspond to the extent of reticular change on HRCT
No
Excess eosinophils (more than 20%): eosinophilic lung disease
Lymphocytosis above 15%: NSIP, COP, hypersensitivity pneumonitis, sarcoidosis or other
granulomatous lung diseases
Surgical lung biopsy- may be needed in cases of IPF, Sarcoidosis, hypersensitivity pneumonitis,
asbestosis, lymphangitic carcinoma, PLCH.
CXRay – most common presentation is bibasilar reticular pattern. Nodular or mixed pattern are also
seen.
HRCT – Both inspiratory + expiratory and supine + prone films are required. Slice thickness of 1 to 1.5
mm is required. If clinical features and chest radiograph suggest hilar enlargement, then contrast is also
required to delineate mediastinal structures.
Sinus CT- may be useful in wegener’s granulomatosis, sarcoidosis.
17. Laboratory tests (relevant):
a) CBC: Hb___ TLC_____Platelets___ MCV ___ DLC: N___ L___ E___ M___ B___
b) B Sugar F ___ PP ___
c) Renal : Urea __________ Creatinine __________
d) Liver function tests: Bilirubin _____ SGOT_____ SGPT ___ Hepatitis Bs __Ab__, Hepatitis
C__ Ab__
e) Urinalysis: Protein _____ Sugar _____ Cast _____ Pus cells _____
f) Sputum: AFB_____ Fungus _____
g) Collagen vascular disease profile:
ANA + -, RF + - , dsDNA + - , Sm + - ,
RNP + - ,
Scl 70 + - , SSA + -,
SSB + - , CPK + - , Anti Jo-1 + - , ANCA + - ACE _____ EBV titer + Collagen vascular disease profile relevant in workup of ILD?
Test
Disease
Anti nuclear antibody
SLE
Anti double stranded DNA (ds-DNA)
Anti Smith (Sm)
RF
Non specific
Rheumatoid arthritis
Anti Ribonucleprotein (RNP)
Mixed connective tissue disorder
Cytoplasmic antinuclear antibody (c-ANCA) Wegner’s granulomatosis
Perinuclear antinuclear antibody (p-ANCA)
Microscopic polyangiitis
Churg strauss
Angiotensin converting enzyme (ACE)
Sarcoidosis
Anti topoisomerase
Systemic sclerosis
Anti SSA (Ro)
SLE
Anti SSB (La)
Sjogren’s syndrome
h) HIV + i) Lymphocyte transformation testing (metals) ________________________________________
j) Mantoux test (PPD) Optional:
k) Echocardiogram (Optional): Date
EF __________________ Wall asymmetry _____________________ Estimated systolic PA
pressure ____________________ RV dilation/thickness ________________
Besides CBC showing anemia or pancytopenia (Gaucher’s disease, marrow suppression by drugs), RFT
and urine examination may show nephritis or nephritic syndrome. LFT should be done for hepatitis,
cirrhosis. Peripheral eosinophilia occur in eosinophilic pneumonia, Churg Strauss syndrome and drug
reactions. Hypercalcemia occurs in sarcoidosis.
ANCA and Anti Basement membrane antibodies are useful in vasculitis. Scl70 in systemic sclerosis and
raised CPK in polymyositis and dermatomyositis.
ECG may show enlargement of RA,RV.
Cardiac echocardiography relevant in work up of DPLD?
Cardiac echocardiography is relevant because –
Cor pulmonale due to chronic hypoxia
Concomitant heart disease
18. Consultant’s impression /opinion
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
A) Suspected ILD diagnosis :
Yes
No
a. Idiopathic Interstitial Pneumonias (IIP)
i. UIP
ii. NSIP
iii.COP
iv. LIP
v. RB-ILD
b. IPF
c. Pulmonary fibrosis of unknown cause other than IIP
d. Occupational ILD
e. Granulomatous diseases eg. Sarcoidosis
f. Hypersensitivity pneumonitis
g. ILD secondary to collagen vascular disease
h. familial ILD
i. Other rare ILD given in appendix D)
B) Suspect active infection (Active TB or pneumonia)
____________________________________________
C) Other coexisting lung disease
______________________________________________________________
D) Comorbidities
___________________________________________________________________________
19. Follow up of the patient:
Date
A. Symptoms:
Improved
Same
Deteriorated
B. New symptoms /finding/diagnosis
____________________________________________________________________________________
____________________________________________________________________________________
C. Investigations:
FEV1
FVC
FEV1/FVC
Predicted
Actual
Percentage
____________________________________________________________________________________
D. Treatment prescribed
____________________________________________________________________________________
____________________________________________________________________________________
Date
A. Symptoms:
Improved
Same
Deteriorated
B. New symptoms /finding/diagnosis
____________________________________________________________________________________
____________________________________________________________________________________
C. Investigations:
FEV1
FVC
FEV1/FVC
Predicted
Actual
Percentage
____________________________________________________________________________________
D. Treatment prescribed
____________________________________________________________________________________
____________________________________________________________________________________