HISTORY:
Shortness of breath for
Graded at: / 4
pillows
Worsening factors:
Treatments tried: ,
Onset:
Pattern:
, ,
,
,
, up to °, over
, over
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Chest X-ray
- ECG
- Blood work: , , , , , , , ,
- CT scan of the chest
- Stress test
- Echocardiogram
- Cardiac catheterization
- Pulmonary function tests
- Sleep study
- Oxygen therapy if SpO2 < 92%
-
-
-
-
- Smoking cessation counseling
- Referral to pulmonologist
- Referral to cardiologist
- Follow-up in
- Return if shortness of breath worsens or if new symptoms develop such as chest pain, palpitations, or syncope