Cough & Pneumonia


HISTORY_LIST
onset of cough
duration of cough
chills
rigors
fever
how high a fever
sputum color
sputum quantity
sputum consistency
sputum odor
pleuritic pain
dyspnea
orthopnea
malaise
sore throat
rhinorrhea
headaches
stiff neck
ear pain
neausea
vomiting
diarrhea
myalgia
arthralgia
recent contact with ill people
living situation: 
nursing home 
hospital
INFECTIOUS DISEASES
recent viral infection
previous pneumonia
pneumocystis
AIDS
immunosupression
CHRONIC DISEASE 
SYSTEMIC DISORDERS
diabetes
heart failure
COPD
asthma
alcoholism
aspiration
exposure to TB
exposure to asbestos
SURGERY 
PREVIOUS HOSPITALIZATIONS
"hospitalizations for resp dz"
PREVIOUS TESTS
CXR
tuberculin testing
HIV testing
SOCIAL HISTORY
smoking
alcohol
IV drug abuse
ALLERGY
medications
foods
seasonal

MEDS_LAB_TESTS
**** MEDS
steroids
chemotherapy
sedatives
pneumococcal vaccination
influenza vaccination
**** LAB
Electrolytes
BUN
Creatnine
CBC
glucose
UA
sputum gram stain
sputum culture and sensitivity
sputum cytology
**** TEST
ECG
CXR
ABG

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
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

REVIEW_OF_SYSTEMS_3
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: 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





PHYSICAL_EVAL_1
VITALS
BP
Pulse
Temp
Heart rate
GENERAL
respiratory distress
dehydration
HEENT
tympanic membranes
throat erythema
lymphadenopathy
NECK
stiff neck

PHYSICAL_EVAL_2
CHEST
unilateral splinting
dullness to percussion
tactile fremitus
rhonchi
fine, high pitched,
   & expiratory crackles
inc. bronchial breath sounds 
whispered pectoriloquy
egophony
EXTREMITIES
clubbing
cyanosis
NEURO
gag reflex
mental status


DIFF_DIAGNOSIS
Pneumonia (possible etiology:
    S pneumoniae,
    H infleuenza, 
    S aureus,
    tuberculosis,
    mycoplasma pneumoniae,
    Legionella,
    Klebsiella pneumoniae,
    Streptococcus pyogenes, 
    Moraxella catarrhalis,
    Chlamydia pneumoniae)
heart failure
asthma
viral infection
PE
aspiration
pneumonitis
malignancy


