COUGH
ESSENTIAL INQUIRIES.
- Age, tobacco use history, and duration of cough.
- Dyspnea (at rest or with exertion) Vital signs (heart rate, respiratory rate, body temperature).
- Chest examination.
- Chest radiography when an unexplained cough lasts more than 3-6 weeks.
Cough adversely affects personal and work-related interactions, disrupts sleep, and often causes the discomfort of the throat and chest wall. Most people seeking medical attention for acute cough desire symptom relief; few are worried about serious illness. Cough results from the stimulation of mechanical or chemical afferent nerve receptors in the bronchial tree.
DYSPNEA
ESSENTIAL INQUIRIES.
- Fever, cough, and chest pain.
- Vital sign measurements; pulse oximetry.
- Cardiac and chest examination.
- Cardiac and chest examination. Chest radiography and arterial blood gas measurement in selected patients.
Dyspnea is a subjective experience or perception of uncomfortable breathing. However, the relationship between the level of dyspnea and the severity of the underlying disease varies widely across individuals. Dyspnea can result from conditions that increase the mechanical effort of breathing (eg, COPD, restrictive lung disease, respiratory muscle).
HEMOPTYSIS
ESSENTIAL INQUIRIES.
- Fever, cough, and other symptoms of lower respiratory tract infection.
- Smoking history.
- Nasopharyngeal or gastrointestinal bleeding.
- Chest radiography and complete blood count (and, in some cases, INR).
Hemoptysis is the excitation of blood that originates below the vocal cords. It is commonly classified as trivial, mild, or massive- the latter defined as more than 200-600 mL (about 1-2 cups) in 24 hours. Massive hemoptysis can be usefully defined as any amount that is hemodynamically significant or threatens ventilation.
CHEST PAIN
ESSENTIAL INOUIRIES.
- Chest pain onset; character, location/size, duration, periodicity, and exacerbators and shortness of breath.
- Vital signs; chest and cardiac examination.
- Electrocardiography and biomarkers of myocardial necrosis in selected patients.
Chest pain (or chest discomfort) is a common symptom that can occur as a result of cardiovascular, pulmonary, pleural, or musculoskeletal disease, esophageal or other gastrointestinal disorders, or anxiety states. Consideration of the diagnosis and rigorous risk factor assessment for venous thromboembolism (VTE) is critical. Classic VTE risk factors include cancer, trauma, recent surgery, prolonged immobilization, pregnancy, oral contraceptives, and family history and prior history of VTE. Other conditions associated with an increased risk of pulmonary embolism include HF and COPD. Sickle cell anemia can cause acute chest syndrome. Patients with this syndrome often have chest pain, fever, and cough.
PALPITATIONS
ESSENTIAL INQUIRIES.
- Forceful, rapid, or irregular beating of the heart.
- Rate, duration, and degree of regularity of heartbeat; age at the first episode.
- Factors that precipitate or terminate episodes.
- Light-headedness or syncope; neck pounding.
- Chest pain.
Palpitations are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart. They are the primary symptom for approximately 16% of patients presenting to an outpatient clinic with a cardiac complaint. While palpitations are usually benign, they are occasionally the symptom of a life-threatening arrhythmia.
LOWER EXTREMITY EDEMA
ESSENTIAL INQUIRIES.
- History of venous thromboembolism.
- The symmetry of swelling.
- Change with dependence.
- Skin findings: hyperpigmentation, stasis dermatitis, lipodermatosclerosis atrophie blanche, ulceration.
Acute and chronic lower extremity edema present important diagnostic and treatment challenges. Lower extremities can swell in response to increased venous or lymphatic pressures, decreased intravascular oncotic pressure, increased capillary leak, and local injury or infection.
FEVER & HYPERTHERMIA
ESSENTIAL INQUIRIES.
- Age; injection substance use.
- Localizing symptoms; weight loss; join pain.
- Immunosuppression or neutropenia; the history of cancer.
- Medications.
- Travel.
The average normal oral body temperature taken in midmorning is 36.7’C (range 36-37.4C). This range includes a mean and 2 standard deviations, thus encompassing 95% of a normal population (normal diurnal temperature variation is 0.5-1’C). The normal rectal or vaginal temperature is 0.5’C higher than the oral temperature, and the axillary temperature is 0.5C lower. Rectal temperature is more reliable than oral temperature, particularly in patients who breathe through their mouth or in tachypneic states. Fever is a regulated rise to a new “set point” of body temperature. When stimuli act on monocyte macrophages, these cells elaborate pyrogenic cytokines, causing elevation of the set point through effects in the hypothalamus. These cytokines include interleukin-1 (IL-1), tumor necrosis factor (TNF), interferon-gamma, and interleukin-6 (IL-6). The elevation in temperature results from either increased heat production (eg, shivering) or decreased heat loss (eg, peripheral vasoconstriction). Body temperature in cytokines induced fever seldom exceeds 41.1C unless there is structural damage to hypothalamic regulatory centers.