subjective data - Answers what the patient tells you
includes: shortness of breath, cough, smoking history, PMH
Shortness of Breath (SOB) - Answers ask questions like:
When did it start? or Are you having any now?
Within the last day, have you had? Is it affected by a position, such as lying down?
How long did/does it last?
DO you have it at activity/rest?
Have you done any treatments/did it help?
orthopnea - Answers difficulty breathing when supine
paroxysmal nocturnal dyspnea - Answers sudden awakening from sleeping with shortness of breath
chronic dyspnea - Answers SOB > 1 month; may have neurogenic, respiratory, or cardia origin; occurs
with anemia, anxiety, and deconditioning
Cough - Answers Ask questions like:
Do you have a cough? When did it start?
Gradual or sudden? How long have you had it?
Does it wake you up at night? Is it productive or nonproductive? If productive, what color is it? Cough up
any blood (looks like coffee grounds)?
acute cough - Answers lasts less than 2 or 3 weeks
chronic cough - Answers persists over 2 months
Characteristic Timing of Cough - Answers continuous throughout day -- acute illness (respiratory
infection)
afternoon/evening -- exposure to irritants at work
night -- postnasal drip, sinusitis
early morning -- chronic bronchial inflammation (smokers)
hemoptysis - Answers coughing up blood
white or clear mucoid sputum - Answers colds, bronchitis, viral infections
, yellow or green sputum - Answers bacterial infections
rust colored sputum - Answers TB, pneumococcal pneumonia
pink frothy sputum - Answers pulmonary edema, some sympathomimetic medications have a side effect
of pink-tinged mucus
Chest Pain with Breathing History - Answers When did it start? Constant, or does it come or go?
Describe the pain: burning, stabbing?
Brought on by respiratory infection, coughing, or trauma?
Treatment? Medication or heat application?
Chest pain of thoracic origin - Answers occurs with muscle soreness from coughing or from inflammation
of pleura overlying pneumonia
History of Respiratory Infections - Answers Any past history, such as bronchitis, emphysema, asthma,
pneumonia?
Any family history of allergies, tuberculosis, or asthma?
Smoking History - Answers Do you smoke? If so, how much per day? Cigarettes or cigars? How old were
you when you started?
Environmental Exposure History - Answers Seasonal, occupation, second hand smoke, CO exposure, and
radon.
General symptoms from Environmental Exposure - Answers cough, SOB,
Some gases produce specific symptoms:
carbon monoxide -- dizziness, headache, fatigue
sulfur dioxide -- cough, congestion
Objective Data include: - Answers inspection, auscultation, palpation
When inspecting, you are looking for... - Answers Level of consciousness (LOC)--alert, awake?
Facial expression--smiling, flat affect, sad, angry
Skin color--pink, pale, dusky, cyanotic
Rate--fast, slow, use of accessory muscle to breath
Rhythm--regular or irregular