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