Cough
Age: years old
Gender:
HISTORY:
Presents with a - history of cough
Described as , with sputum
Severity is
Pattern , worse during the
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
,
, , , ,
, up to °, over
, over ,
Contributing factors:
no history of: , , , , , , , ,
no use of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: upper respiratory infection, viral URI, post-nasal drip, acute sinusitis, bronchitis, asthma, GERD, pneumonia, chronic obstructive pulmonary disease (COPD), allergic rhinitis, tuberculosis, lung cancer, foreign body aspiration, ACEI-induced cough
PLAN:
Investigations:
- Chest X-ray
- Covid test, Influenza test
- Blood work: , , , , ,
- Sputum culture
- Allergy testing
- Respiratory function tests
Treatments:
- Saline nasal irrigation
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-
-
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-
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- Smoking cessation counseling
- Stop ACE inhibitors
Further care:
- Referral to pulmonologist
- Referral to ENT specialist
- Follow-up in
- Return if cough persists for more than 3 weeks, if new symptoms develop, or if condition worsens
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: