Wheezing & Asthma HISTORY_LIST onset acuteness of onset duration & progress of wheeze dyspnea purulent sputum frequency of exacerbation home oxygen or nebulizer Symptom provocation: activities or seasons occupational exposures exacerbation by exercise exacerbation by emotions chest pain edema foreign body aspiration INFECTIOUS DISEASES recent respiratory infection CHRONIC DISEASE SYSTEMIC DISORDERS emphysema bronchitis pneumonia coarse of previous episodes SURGERY PREVIOUS HOSPITALIZATIONS last hospitalization for severe wheezing/asthma last intubated treatment in emergency room response to ER treatment PREVIOUS TESTS CXR baseline ABG past PFT's skin allergy testing SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal FAMILY HISTORY asthma allergies hay fever atopic dermatitis eczema uticaria use of home dust/pollen control MEDS_LAB_TESTS **** MEDS aspirin NSAIDS beta blocker bronchodilators theophylline prednisone albuterol ipratropium bromide **** LAB ABG Electrolytes BUN Creatnine CBC theophylline level sputum gram stain and culture **** TESTS 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 mitral 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 Postural BP Pulse Temp Heart rate pulsus paradoxus GENERAL dyspnea interruption of sentences by respiration respiratory distress diaphoresis somnolence SKIN atopic dermatis urticaria insect bites HEENT conjuctival injection edema cobblestoneing of eyelid nasal flaring, erythema & congestion otitis media pharyngeal studding facial cyanosis NECK JVD stridor tracheal deviation PHYSICAL_EVAL_2 CHEST bilat. decreased breath sounds accessory muscle use barrel chest inc anterioposterior diameter retractions prolonged expiratory wheeze rhonci unilateral increased hollow resonance note on percussion HEART right ventricular heave decreased cardiac dullness to percussion S3 gallop increased pulmonic component of S2 (P2) ABDOMEN retractions inferior descent of hepatic dullness tenderness EXTREMITIES cyanosis edema clubbing NEURO mental status confusion drowsiness DIFF_DIAGNOSIS asthma bronchitis emphysema pneumonia heart failure toxic fumes upper airway obstruction (foreign body, tumor, laryngeal, edema) carcinoid PE vasculitis vocal cord dysfunction aspergillosis