Sinai-Grace Internal Medicine Residency
Ambulatory Clinic Documentation Guides
Asthma
- HISTORY
- Any shortness of breath, cough,
wheeze – daytime/nighttime frequency?
- Any post-nasal drip/GERD symptoms?
- Any ED visits/hospitalizations/ICU
admission/intubations since last visit?
- Current maintenance therapy and
rescue therapy
- Known
triggers
- Exposure
to cigarette smoke
- Any
exposure to animal dander/cockroaches/dustmites
- Any
carpeting in the room, mattress box not wrapped in plastic, feather
pillow?
- Baseline
Peak Flows
- Any PFTs in the past?
- Number
of yearly ED visits/hospitalizations/ICU admission/intubations
- Last
systemic steroids use
- Last
Pneumovax and flu shot
- PHYSICAL EXAM
- Peak Flows – each visit if patient
brings in their meter.
- General – shortness of breath, able
to speak in full sentences, level of conciousness,
accessory respiratory muscle use
- Ears – tympanic membrane
- Sinuses - tenderness
- Nose – enlarged turbinates,
discharge
- Throat and Oral Cavity – posterior
pharyngeal wall erythema or exudates
- Lungs – wheezes, rhonchi,
signs of consolidation
- Abdomen – epigastric
tenderness
- INVESTIGATIONS
- Peak Flows – each visit if patient
brings in their meter.
- PFTs -baseline
- CXR –
baseline