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