Respiratory System

#Respiratory System

S: Subjective

Presenting Complaints:
(-) fever
(-) chills
(-) night sweats
(-) weight loss

(-) sore throat
(-) dysphonia
(-) rhinorrhoea
  (-) clear
  (-) coloured/purulent
  (-) blood-stained

(-) cough
(-) sputum production
  (-) clear
  (-) coloured/purulent
  (-) blood-stained
(-) haemoptysis

(-) chest pain on exertion
(-) chest pain at rest
(-) dyspnoea on exertion
(-) orthopnoea
(-) paroxsysmal nocturnal dyspnoea
(-) dyspnoea at rest
(-) wheeze
(-) nocturnal choking or gasping
(-) enlarged lymph nodes

(-) other ->

Symptom Development:
- Onset/triggers: 
- Aggravating factors: 
- Relieving factors:

Past Medical History: 
(-) allergic rhinitis
(-) chronic rhinitis/sinusitis
(-) asthma
(-) atopic eczema
(-) COPD
(-) pneumonia
(-) pneumothorax
(-) tuberculosis
(-) lung neoplasm -> 
(-) other neoplasm -> 
(-) abnormal chest X-ray/imaging -> 
(-) obstructive sleep apnoea
(-) GORD

Treatment History: 
(-) chest surgery -> 
(-) pleurodesis
(-) inhaled bronchodilators
(-) inhaled corticosteroids
(-) oral corticosteroids
(-) hospitalisation for a respiratory condition ->

Social History: 
(-) current smoker -> 
(-) past smoker ->

Occupational History / Environmental Exposures:
(-) mining
(-) silica
(-) asbestos
(-) other dust
(-) farming
(-) milling/baking

Family History: 
(-) asthma
(-) COPD/emphysema
(-) tuberculosis
(-) other ->

O: Objective **abnormalities**

(-) Skin colour: 
(-) Heart rate (bpm): 
(-) Blood pressure (mmHg): 
(-) Respiratory rate (/min): 
(-) SpO2 (%): 
(-) Temperature (deg. C):

(-) 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 [adults >5 cm]

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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