Pulmonary Embolism

HISTORY_LIST
sudden onset of pleuritic chest
  pain and dyspnea
unilateral leg pain and swelling
cough
hemoptysis
diaphoresis
syncope
INFECTIOUS DISEASES
pneumonia
CHRONIC DISEASE 
SYSTEMIC DISORDERS
PE
DVT
valvular dz.
Virchow's Triangle of immobility, 
  trauma, and hypercoagulability
malignancies of  
   pancreas, 
   lung, 
   genitourinary, 
   stomach, 
   breast
heart failure
SURGERY 
PREVIOUS HOSPITALIZATIONS
any type surgery
PREVIOUS TESTS
ventilation-perfusion scan
CXR
ECG
TRAUMA OR INJURIES
any trauma
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
obesity
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
obesity
heart failure
blood disorders
hypercoagulability

MEDS_LAB_TESTS
**** MEDS
oral contraceptives (estrogen)
PEName
VITALS
BP
Pulse
Temp
Heart rate
**** LAB
ABG
Electrolytes
BUN
Creatnine
CBC
**** TESTS
ventilation-perfusion scan
pulmonary angiogram
ECG
CXR

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



PHYSICAL_EVAL_1
GENERAL
dyspnea
apprehension
diaphoresis
NECK
JVD
prominent A-wave
CHEST
crackles
tenderness or splinting of 
   chest wall
pleural friction rub
breast mass
HEART
right ventricular gallop
tachydysrhythmia
accentuated, loud pulmonic 
      component of S2 (P2)
GU
testicular mass
pelvic mass
EXTREMITIES
cyanosis
calf redness, tenderness, and warmth
Homan's sign 
  pain with dorsiflexion of the foot
increased calf circumference 
  > 2 cm difference in both calves
pitting edema
NEURO
altered mental state


PHYSICAL_EVAL_2

DIFF_DIAGNOSIS
PE
pneumonia
pneumothorax
bronchitis
asthma
pulmonary edema
pericarditis
MI
neoplasm
muscle or rib injury
myositis
subdiaphragmatic irritation


