Subjective (Reports)
Dyspnea/related to: _______________ Precipitating factors:_______________
Relieving factors:_______________
Airway clearance (e.g., spontaneous/device):________________________________________________________
Cough (e.g., hard, persistent, croupy):_______________ Sputum color/character:_______________ Requires suctioning:_______________
History of/date: Bronchitis:_____ Emphysema:_____ Tuberculosis:_____ Recurrent pneumonia:_____
Exposure to noxious fumes/allergens, infectious agents/diseases, poisons:
_____________________________________________________________________________________________
Smoker:__________ packs/day:__________ # of pack years:__________ Cigar use:__________ Smokeless:__________
Use of respiratory aids:_________________________ Oxygen (type & frequency):_________________________
Medications/herbals:______________________________________________________________________________________________________________
Objective (Exhibits)
Respirations (spontaneous/assisted):_____ Rate:_____ Depth:_____ Chest excursion (e.g., equal/symmetrical):_____
Use of accessory muscles:_______________ Nasal flaring:_______________ Fremitus:_______________
Breath sounds (describe):_________________________ Egophony:_________________________
Skin/mucous membrane color (e.g., pale, cyanotic):____________________
Clubbing of fingers:______________________
Sputum characteristics:_________________________________________________________________________
Mentation (e.g., calm, anxious, restless):_______________________________________________________________________
Pulse oximetry:_____________________________________________________________________________________
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