Respiratory system

{Respiratory system}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] fever
[-] chills
[-] night sweats
[-] weight loss

[-] sore throat
[-] dysphonia
[-] rhinorrhoea
  [-] clear
  [-] coloured/purulent
  [-] blood-stained

[-] cough
[-] sputum production
  [-] clear
  [-] coloured/purulent
  [-] blood-stained
[-] wheeze
[-] haemoptysis

[-] chest pain on exertion
[-] chest pain at rest
[-] dyspnoea on exertion
[-] dyspnoea at rest
[-] orthopnoea
[-] paroxsysmal nocturnal dyspnoea
[-] nocturnal choking or gasping
[-] enlarged lymph nodes

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[-] allergic rhinitis
[-] chronic rhinitis/sinusitis
[-] asthma
[-] bronchitis
[-] atopic eczema
[-] COPD
[-] pneumonia
[-] pneumothorax
[-] tuberculosis
[-] lung neoplasm: 
[-] other neoplasm: 
[-] abnormal chest X-ray/imaging: 
[-] obstructive sleep apnoea
[-] GORD

Respiratory treatment history: 
[-] chest surgery: 
[-] pleurodesis
[-] inhaled bronchodilators
[-] inhaled corticosteroids
[-] oral corticosteroids
[-] hospitalisation for a respiratory condition:

SOCIAL HISTORY
Smoking:
[-] never smoked
[-] current smoker
[-] ex-smoker
  If smoker, pack-year history:

Occupational history and environmental exposures:
[-] mining
[-] silica
[-] asbestos
[-] other dust
[-] farming
[-] milling/baking

FAMILY HISTORY
[-] asthma
[-] COPD/emphysema
[-] tuberculosis

[Vital signs]

Skin colour: 
Temp (deg.C): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%):

PHYSICAL EXAMINATION
Relevant examination findings: {abnormalities}
[-] audible stridor/wheeze
[-] cyanosis
[-] tracheal deviation
[-] chest deformity
  [-] asymmetry
  [-] barrel chest
  [-] pectus excavatum
  [-] pectus carinatum
  [-] chest scars
[-] right ventricular heave
[-] dullness to percussion
[-] raised JVP
[-] finger clubbing
[-] peripheral oedema

Auscultation: 
  Right: 
    [-] wheeze 
    [-] crackles 
    [-] friction rub 
    [-] vocal fremitus

Left:
    [-] wheeze 
    [-] crackles 
    [-] friction rub 
    [-] vocal fremitus

Chest expansion cm {normal adult >5}:

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

patient information and advice:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260201]

Respiratory system

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