COPD

HISTORY_LIST
***** HISTORY OF PRESENT ILLNESS
onset
acuteness of onset
duration and progress of wheeze
dyspnea
purulent sputum
frequency of exacerbations
home oxygen or nebulizer
activities or seasons that 
   provoke symptoms
occupational exposures
exacerbaton by exercise
exacerbaton by emotions
chest pain
chest trauma
***** HISTORY
INFECTIOUS DISEASES
recent respiratory infection
CHRONIC DISEASE
SYSTEMIC DISORDERS
emphysema
bronchitis
pneumonia
coarse of previous episodes
diabetes
heart failure
SURGERY
PREVIOUS HOSPITALIZATIONS
last hospitalization for severe
   wheezing or asthma
last intubated
treatment in emergency room
response to ER treatment
PREVIOUS TESTS
CXR
baseline ABG's
PFT's
skin allergy testing
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
asthma
allergies
hay fever
atopic dermatitis
eczema
urticaria
use of home dust or 
   pollen control measures

MEDS_LAB_TESTS
***** MEDS
oxygen
aspirin
NSAIDS
beta blockers
bronchodilators
Theophylline
Prednisone
Albuterol
Ipratropium bromide
***** LAB
ABG's
Electrolytes
BUN
Creatnine
CBC
Theophylline level
sputum gram stain and culture
***** TESTS
ECG
CXR
DDX
COPD
PE
epiglotitis
asthma
bronchitis
emphysema
pneumonia
heart failure
upper airway obstruction 
 (foreign body)
 (tumor)
 (laryngeal)
edema
pneumothorax
anaphylaxis
aspiration

REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
VITALS
BP
Postural BP
Pulse
Temp
Heart rate
pulsus paradoxus
GENERAL
dyspnea
interruption of sentences by
   respiration
respiratory distress
diaphoresis
cachexia
pink puffer
blue bloater
HEENT
pursed lip breathing
mucus membranes cyanosis 
perioral cyanosis
NECK
JVD
stridor
tracheal deviation
expiratory duration

REVIEW_OF_SYSTEMS_3
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

PHYSICAL_EVAL_1
CHEST
bilateral decreased breath sounds
accessory muscle use
barrel chest
increased anterioposterior
diameter
retractions
prolonged expiratory wheeze
rhonci
unilateral
increased hollow resonance note
   on percussion
HEART
right ventricular heave
S3 gallop
ABDOMEN
retractions
EXTREMITIES
cyanosis
edema
clubbing
NEURO
mental status
confusion
drowsiness
somulence

PHYSICAL_EVAL_2
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty in fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
hospitalization for 
psychiatric problems
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia

DIFF_DIAGNOSIS


