Adam Sawyer is an 18-year-old male who has been experiencing a fever, cough, and shortness of breath for the past week. Take a detailed history and perform a focused physical examination. Vitals: BP - 110/70 mm Hg, HR – 96/min, RR – 20/min, Temp – 38.5°C.
History of present illness
- Duration/Onset: How long have you had the cough? (chronic >8wks) Sudden or gradual in onset?
- Frequency: How often do you cough? How many times during the day? Do you have a cough all day or only at certain times of the day? How long does each attack last? (Differential diagnosis of the chronic cough based on the time of the day: Morning: Sinusitis, GERD, Night: CHF, GERD, asthma)
- Quality: Dry or productive? If productive, sputum characteristics (COCA+-Blood)
- Provoking/Relieving factors: Anything that aggravates (exercise, smoke, weather) or makes the cough better (inhaler use, rest, sitting upright, antacids)?
- Associations: Dyspnea, hemoptysis, wheezing, chest pain, orthopnea, PND, rhinitis, reflux, post-nasal drip.
- Constitutional Symptoms: Fever, chills, fatigue, night sweats, appetite, weight loss?
🚩 RED FLAGS: Fever, night sweats, weight loss, weight gain with peripheral edema, hemoptysis, severe dyspnea, dysphagia, hoarseness of voice, current tobacco use, recurrent pneumonia (eg. atypical infection, immunodeficiency, aspiration)
Past medical/surgical history
- Lung (asthma, COPD, CF), heart (CHF, MI, arrhythmias), chronic illness, GI (reflux)
- Medications (e.g. ACEI, β-blockers), allergies
- Vaccination for pneumococcus or flu?
- TB status, HIV status?
Social / Family history
- Family history of lung CA or other CA
- Smoking (Tobacco history 20 pack years or smoker over age 45 years)
- Occupation, recent travel? Sick contacts