Presenting Complaint
1. Cough
Acute cough- Infection, Allergy, Asthma/COPD
Chronic cough - Smoking, Asthma/COP, post-nasal drip, Lung Carcinoma, TB
2. Sputum
- How much are you bringing up in a day? (tsp, tbsp, cup etc)
- How much would you normally bring up?
- What colour is it?
- Is this usual for you – what colour is it normally?
- Have you ever seen blood / pink discoloration in it?
- Can you comment on the taste / smell?
- Can you describe the consistency? (thick, sticky, watery, frothy)
- Do you have trouble getting it up?
Copious amounts of purulent sputum are characteristic of an infective exacerbation of COPD. Large amounts of frothy-white/pink sputum are seen in cardiac failure.
Some causes of sputum production -
1.Infection
2.Smoking
3.COPD
4.Bronchiectasis
5.Lung CA
6.TB
7.Pulmonary oedema
3. Haemoptysis
- Have you ever coughed up blood / bloodstained sputum?
- Can you describe it? (blood flecks, bright / dark red, pink & frothy, clots)
- How long has this been going on for?
- How many times has it happened?
- How much on each occasion?
1.Lung carcinoma
2.Pulmonary embolism
3.TB
4.Pneumonia
5.Bronchiectasis
6.Cystic Fibrosis
4. Dyspnoea
- How long have you been feeling breathless?
- Is it getting worse?
- What brings it on?
- How far can you run / walk / climb before it happens?
- Are you ever breathless at rest?
- Do you ever feel breathless in bed?
- How is it affecting your life?
1.COPD
2.Asthma
3.Pneumonia
4.Pneumothorax
5.Lung carcinoma
6.Pulmonary embolism
7.Pulmonary fibrosis
8.Cystic Fibrosis
9.Pleural effusiom
10.Left ventricular failure
5. Wheeze
- What brings it on? (allergens, exercise, cold air, stress, smoke, dust)
- How often do you get an attack?
- Is this more often than usual?
- How do you relieve it? Does this help?
- How is it affecting your life?
- Have you ever had to attend A&E with an attack?
- Were you ever ventilated?
Acute- Respiratory infection, Foreign body aspiration
Chronic -Asthma, Chronic infection, Cystic Fibrosis, Bronchiectasis, Mediastinal masses, Cardiac wheeze (LVF)
6. Chest pain
- How long have you had this chest pain?
- Is it worse on taking a deep breath?
- Was it of gradual or sudden onset?
7. Fever
- Is patient febrile?
- Are they checking their temperature?
8. Hoarseness
Is this a new problem?
How long is it going on?
9. Night sweats
How long is it going on?
Do they have to change their night clothes and bed sheets?
8. Sneezing - Rhinitis
9. Weight loss- Weight loss may be associated with Respiratory neoplasm, Chronic infection, e.g. COPD/Cystic Fibrosis
History of Presenting Complaint
Previous respiratory illness [asthma, pneumonia, TB, COAD, Tumour]?
Abnormal CXR?
Any chest problems as a child?
Any allergies?
Previous admissions?
Previous operations?
Video Assisted Thoracoscopy for biopsy
Chest drain insertion
Lobectomy
Pneumonectomy
Past Medical/Surgical History
Other medical/surgical problems
Medication
Prescribed and over the counter
Bronchodilators/inhalers
Home nebuliser
Home oxygen
Antihistamines
Antibiotics
Steroids
Allergies
To any medication
Document the reaction which occurred, e.g. nausea/vomiting/rash/wheeze/bronchospasm/loss of consciousness.
Social History
Marital status/children
Employment
Home situation
Alcohol intake [count units per week]
Smoking history
Recent travel
Vaccinations
Do you keep pets?
a.Do you smoke? / Have you ever smoked?
b.How many cigarettes do you smoke in a day?
c.Have you ever smoked more / less?
d.Have you ever tried to give up?
e.Were you successful?
f.Passive smoking in work place/at home
Occupational History
Exposure to dust in mining industry/factories [asbestos/coal]
Exposure to mouldy hay [allergic alveolitis]
Exposure to birds [psittacosis]
Family History
Any family history of respiratory disease
Asthma
Cystic Fibrosis
Emphysema
Alpha-1-anti-trypsin deficiency
Any other illness in family
Complete Systems Review
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