PART 1
Katie
CC: “Cough that is not getting better, tired and easily winded on walks,”
HPI:
Onset: One week ago, (Pneumonia (CAP), Bronchitis, Asthma, Congestive Heart Failure)
Location: not specified: Do you have post nasal drip? Does the cough feeling like its coming
from your throat or chest? (Pneumonia (CAP), Bronchitis, Asthma, Congestive Heart Failure)
Duration: Worse at night. How frequent are you coughing? Any other time of day it is worse?
Have you ever had these symptoms before? If so how often? (Pneumonia (CAP), Bronchitis,
Asthma, Congestive Heart Failure)
Characteristics: Tired and easily winded: How would you describe your cough; hacking, dry,
barking, hoarse, congested, or bubbling? (Pneumonia (CAP), Bronchitis, Asthma, Congestive
Heart Failure)
Aggravating factors: not specified: Is there anything that makes your cough worse? Does
talking, activity, or position make your cough worse? (Pneumonia (CAP), Bronchitis, Asthma,
Congestive Heart Failure)
Relieving factors: not specified: Have you tried anything to relieve your cough such as
lozenges, hot tea, sipping on water, or humidifier? (Pneumonia (CAP), Bronchitis, Asthma,
Congestive Heart Failure)
Treatment: not specified: What treatments have you tried? Have you taken prescription or OTC
medications, used a humidifier, rest, or change positions? (Pneumonia (CAP), Bronchitis,
Asthma, Congestive Heart Failure)
Severity: Hasn’t exercised and gets easily winded. On a scale of 1-10 what is your discomfort
with the cough or breathing? (Pneumonia (CAP), Bronchitis, Asthma, Congestive Heart Failure)
ROS: Additional questions that I would ask:
CONSTITUTIONAL: Any weakness, chills, nausea, vomiting, night sweats?
HEENT: Do you have a headache? Do you have watery or purulent drainage from eyes? Are
you experiencing ear pain or drainage? Do you have nasal congestion or sinus pressure? Do you
have a sensation of throat swelling or neck stiffness? Do you have swollen lymph nodes?
CARDIOVASCULAR: Any chest tightness, pain, heaviness, palpitations, or irregular heart
rate?
RESPIRATORY: Any shortness of breath or hard-breathing with exertion? Wheezing? Sputum
production and if so what color or texture is it? Do you get frequent respiratory infections?
Have you ever had an asthma attack, pneumonia or bronchitis? Is it difficult to breathe when
lying down? Do you feel like you can’t “Catch” your breath?
ABDOMINAL: Have you had any nausea, vomiting, abdominal pain, changes in appetite?
LYMPHATICS: Do you have any pain or tenderness in your neck? Swollen lymph nodes?
DIFFERENCIALS:
Community Acquired Pneumonia (CAP) (IDC-10: J18.9): Streptococcus pneumoniae,
Staphylococcus aureus, and Haemophilus influenzae viruses are the most common viral cause of
community acquired pneumonia (Kaysin & Viera, 2016). CAP is a leading cause of death with
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