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Vital signs
Head, mouth/throat, teeth/gums evaluations, including indicators of
inflamed tongue, inflamed throat, dental or periodontal ailment,
nasal blockage or drainage, or sinus tenderness
Thorough outline of cough (dry hacking, productive)
Description of sputum, if productive
Respiratory examination, including dyspnea, wheezing, rales-rhonchi,
use of accessory muscles, any cyanosis
Soreness with coughing
O2 sats.
Any signs connected to the gastrointestinal (GI) tract, such as
epigastric discomfort or abdominal discomfort


Patient’s age and sex
Onset, length of time, regularity, exacerbating and alleviating factors
Any symptoms linked to nasal congestion, post nasal drip, sore
throat, etc.
Whether coughing has any relation to meals (if coughing happens a few
hours after eating, etc. )
Whether or not coughing is associated with patient’s position (worse when
lying down, etc. )
Whether cough is persistent or intermittent, or is disturbing sleeping
Any recent history of pneumonia, bronchitis, tracheitis, or sinusitis
Previous meal intake (aspiration)
Hx of aspirations?
Any background of smoking
Does cough improve upon subjection to cool air?
All current medicines, including any recent alterations, particularly
prescription drugs associated with cough such as ACE inhibitors
All present diagnoses
Any recent labs (CBC, electrolytes) and diagnostic assessments

Description of sputum:
White or mucoid sputum is frequently observed with
common colds, viral infections, or bronchitis
Yellow or green sputum is generally associated
with bacterial infections
Blood in the sputum is connected with more
serious conditions
Rust tinted sputum is associated with
tuberculosis or pneumococcal pneumonia
Pink frothy sputum may be indicative of
pulmonary edema
Listen to lung noises:
Crackles: These are high pitched,
discontinuous sounds similar to the sound
generated by rubbing your hair in between your
fingers (also known as Rales).
Wheezes: These are generally high pitched and
“musical” in quality. Stridor is an inspiratory
wheeze associated with upper airway
blockage (croup).
Rhonchi: These often have a “snoring” or
“gurgling” quality. Any additional sound that is not
a crackle or a wheeze is in all probability a rhonchi.

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