Hemoptysis


HISTORY_LIST
onset
acuteness of onset
quantity of blood
color
character of sputum
dyspnea
pleuritic chest pain
hoarseness
foreign body aspiration
nasal or sinus pain
leg pain or swelling
foreign travel
farm exposure
INFECTIOUS DISEASES
exposure to TB
exposure to asbestos
CHRONIC DISEASE
   OR SYSTEMIC DISORDERS
AIDS exposure
valvular dz.
bronchitis
SURGERY 
   OR PREVIOUS HOSPITALIZATIONS
lung biopsy
lung surgery
PREVIOUS TESTS
bronchoscopy
prior CXR
tuberculin testing
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
bleeding disorders

MEDS_LAB_TESTS
**** MEDS
**** LAB
sputum for gram stain, KOH,
  acid fast stain, & cytology
pH of expectorant blood
  (alk = pulmonary; acid = GI)
UA
PPD
coccidiomycoses skin test
Electrolytes
BUN
Creatnine
CBC
platelets
ABG
LFT's
PT/PTT
bleeding time
anti-glomerular 
  basement membrane antibodies
**** TESTS
ECG
CXR
CT scan of chest



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 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
MEDSNmae
anticoagulants
heparin
coumadin
NSAIDS
aspirin


PHYSICAL_EVAL_1
VITALS
BP
Postural BP
Pulse
Temp
Heart rate
GENERAL
dyspnea
respiratory distress
SKIN
purple plaques 
  (Koposi's sarcoma)
rashes
  (paraneoplastic syndrome)
HEENT
sinus tenderness
nasal lesions
oropharyngeal lesions
telangiectasias on lips
   or buccal mucosa
ulceration of nasal septum
dental carries
gum disease
cervical lymph nodes
scalene adenopathy
supraclavicular adenopathy

PHYSICAL_EVAL_2
NECK
JVD
CHEST
stridor
tenderness
splinting of chest wall
rhonchi
apical crackles (TB)
localized wheezing
basilar crackles (PE)
pleural friction rub
breast mass
HEART
mitral stenosis murmur 
  (diastolic rumble & snap)
accentuate, loud, S2
ABDOMEN
abdominal masses
liver nodules
abdominal tenderness
GU
occult blood
EXTREMITIES
petechiae
ecchymoses
cyanosis
redness
tenderness
increased calf circumference
clubbing
edema
bone pain
NEURO
cranial nerve palsies
tremor
weakness


DIFF_DIAGNOSIS
bronchitis
bronchiectasis
pneumonia (legionella)
TB
lung abscess
bronchogenic/metastatic
   malignancies
PE
heart failure
trauma to chest
foreign body aspiration
mitral stenosis
pulmonary aneurysm
Goodpasture's syndrome
arteriovenous malformation
aortic aneurysm
aspergilloma
viral/fungal infection
coagulopathy
cystic fibrosis
laryngeal tumor
vasculitis
hemosiderosis
brocholithiasis
benign familial hematuria
SLE
brochoscopy trauma
pulm artery rupture from cath
telangiectasias : lips
   or buccal mucosa 
   (Rendu-Osler-Weber Dz.)
ulceration of nasal septum
  (Wegner's granulomatosis)
gum disease
  (lung abscess)
scalene,  
  supraclavicular adenopathy
  (Virchow's nodes)
  indicative of lung abscess



