- CC:
- Onset: first time? When? Sudden\gradual? Continues\intermittent? Duration? Recent URTI?
- Timing: day\night? After exercise? Seasonal variation? How frequent?
- Character: dry? Productive? Coughing up blood? Barking?
- Aggravating\relieving factors: dust, cold air, animal dander, laying down, medications?
- Severity: wakes you up from sleep? Interfering w\ ADL? How many pillows do you sleep on?
- Associated sx:
- Constitutional: fever, wt loss, loss of appetite, night sweats, chills?
- Resp: chest pain, SOB, PND, wheezing?
- Cardiac: palpitations, LL swelling, claudication?
- GI: abdominal pain, N\V, heartburn, change of BM?
- URTI: runny nose, hoarseness, swollen lymph nodes?
- Atopy: eczema?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM, DLP)
- Respiratory ds (asthma, COPD)
- Cardiac ds
- CF
- Medications: OTC, herbals
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx, contact with sick pts?
- Diet, exercise