Demographic Data:
- Name
- Age
- Gender
- Address
- Marital Status
- Religion
- Occupation
- Source of Referral
- Date of Assessment
Chief Complaint:
- Breathlessness
- Cough with or without Expectoration
- Chest Pain
- Noisy Breathing
- Wheezing
- Stridor
Associated Complaints:
- Hemoptysis
- Hoarseness
- Restlessness
- Voice Changes
- Dizziness
- Faintness
- Syncope
- Ankle Swelling
- Cyanosis
Constitutional Problems:
- Fever
- Excessive Sweating
- Loss of Appetite
- Nausea
- Vomiting
- Weight Loss
- Fatigue
- Weakness
- Exercise Intolerance
- Altered Sleep
Subjective Examinations:
- History of Present Illness or Present Medical History
Description of Symptoms:
- Description of Onset (Date, Time, Type: Gradual or Sudden)
- Duration (How Long)
- Constant and Intermittent
Aggravating Factors:
- Position
- Anxiety
- Weather
- Exercise
- Temperature
Relieving Factor:
- Position
- Cold
- Hot
- Rest
Frequency:
- How often
- Course from onset till present (better, worse, or same)
Associated Symptoms:
- Sweating
- Cough
- Chest discomfort
Activities Disturbed by Breathlessness:
- Climbing stairs (if yes, how many steps)
- Walking (if yes, how much distance is covered)
- Bathing
- Shopping
- Toileting
- Grooming
- Dressing
- Combing
- Any other activities
Objective Assessment:
- Physical Measurements:
- Height
- Weight
- BMI
- Vital Signs:
- Temperature
- Pulse Rate
- Respiratory Rate
- Blood Pressure
- Observations:
- Head:
- Facial Expression
- Lips: Cyanosis, Pursed lip breathing
- Pulse
- Breathing
- Neck:
- Position of Trachea (Midline, Right or Left)
- Jugular Venous Pressure (Normal, Increased, or Markedly Increased)
- Use of Accessory Muscles
- Head:
Cough:
- Description of onset, date, time, and type
- Duration (how long)
- Constant or intermittent
- Frequency (how often, particular day, week, or season)
Aggravating Factors:
- Position
- Weather
- Temperature
- Anxiety
- Exercise
- Smoking
- Location
Relieving Factor:
- Position
- Hot
- Cold
- Medication
- Rest
- Course from onset till present (better, worse, or same)
Associated Symptoms:
- Chest pain
- Fever
- Runny nose
- Night sweats
- Weight loss
- Headache
- Dizziness
- Loss of consciousness
- Severity (how bad it is, how it affected activities of daily living)
Sputum:
- Description of onset, date, time, and type
- Mucoid
- Mucopurulent
- Purulent
- Blood tinged
- Color (colorless like egg, white, black, brownish, pink, greenish, rusty)
- Consistency (thin, thick, viscous, tenacious, frothy)
- Quality (scanty, teaspoon, cup, copious)
- Time of the day (morning, evening)
Hemoptysis:
- Amount
- Clot
- Massive
- Acute
- Chronic
- Frequency
- Associated symptoms like warmth, bubbling sensation with chest pain, dyspnea without coughing, nausea, vomiting, cough
History:
- History of smoking
- History of nosebleed
- History of accidents
- Exposed to patients with tuberculosis
- History of recent surgery
- Family history
- Bleeding disorder
- Medications such as aspirin, oral contraceptives, etc.
Chest Pain:
- Origin
- Location
- Onset, date, time, and type
- Pattern
- Frequency (how often)
- Duration (how long it lasts, constant or intermittent)
- Course (better, worse, or staying the same)
- Aggravating factors (breathing, positions, lying flat, side lying movement with arms rest and exercise, sleeping after eating, stress, and anxiety)
- Relieving factors (rest, position, energetics, antacids, cold, hot)
- Severity (how it affects activities of daily living and VAS scale)
- Associated Symptoms:
- Cough
- Breathlessness
- Palpitations
- Hemoptysis
- Vomiting
- Leg Pain
- Weakness
- Muscle Fatigue
- Time Frame:
- Acute or Chronic
- Past History of Treatment and Pain History
- How it is:
- Subside Medicine
- Heart Infection
- Pulmonary Disease or Accident
- Recent Infection
- Family History of Heart Disease
- Past Medical History
- Surgeries and Hospitalization
- Injuries
- Accident
- Allergies
- Medication
- Diabetes
- Hypertension
- Personal History:
- History of Smoking
- Type of Tobacco
- Age when the patient started smoking, and for how many years
- Number of cigarettes smoked each day
- Any variation in smoking habits
- Any attempt to stop smoking
- Date when the patient last smoked
- Packs per day
- History of alcohol intake
- Age when he started drinking, and for how many years
- Number of packs consumed each day
- Any variation in alcohol habits
- Any attempt to quit
- Date when the patient last drank
- Family history
- Occupational history
- Environmental and socio-economic history
Thorax Assessment:
- COPD Posture:
- Rounded Shoulders
- Protruded Neck
- Kyphosis
- Outstretched Hands
- Chest Wall Deformities:
- Pectus Carinatum
- Pectus Excavatum
- Kyphosis
- Silicosis
- Types of Breath:
- Rapid
- Shallow
- Deep
- Effort of Breathing:
- Minimal on Exhalation
- Passive on Inhalation
- Pattern of Breathing:
- Thoracoabdominal
- Abdominal
- Abnormal Breathing Patterns:
- Apnea
- Biots
- Cheyne-Stokes
- Kussmaul's
- Paradoxical
- Asthmatic
- Failed Chest
- Extremities Examination:
- Upper Limb:
- Clubbing
- Cyanosis
- Tremor
- Lower Limb:
- Edema
Palpation:
- Tracheal Position
- Tenderness on Accessory Muscles
- Palpation of Lymph Nodes (Axillary, Cervical, and Supraclavicular)
- Percussion of Nodes (Resonant, Hyper-resonant, Stony Dullness, Woody Dullness)
- Edema (Pitting, Non-pitting, Grade, Level, or Extent)
- Peripheral Skin Temperature
- Auscultation:
- Quantity and Quality of Breath Sounds
- Chest Expansion (Upper, Middle, Lower)
- Percussion Notes (Hyperresonance, Dullness)
- Tactile Vocal Fremitus
- Presence of Adventitious Sounds (Increased, Decreased, Absent, or Normal)
