QUESTIONAIRE—CHRONIC COUGH AND LARYNGOSPASM



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CHRONIC COUGH, LARYNGOSPASM, NEURALGIA

NAME: ____________________________________ DATE: _________________________

DATE of BIRTH: ____________AGE: _________ OCCUPATION: ____________________

WHO REFERRED YOU TO THIS OFFICE? FRIEND________PHYSICIAN_______OTHER___

WOULD YOU LIKE A REPORT SENT TO YOUR PHYSICIAN REGARDING TODAY’S VISIT?

IF YES, PLEASE LIST: PHYSICIAN NAME___________________________________________

ADDRESS____________________________________________________

Street City State Zip

1) When did your coughing or laryngospasm problem begin? (number of months or years): _______________________________________________________________________

2) At the beginning, what did it seem started the cough or laryngospasm? Please circle all that apply:

-upper respiratory infection -bronchitis or pneumonia

-surgery on my neck -surgery on my chest -other____________________

3) Do you experience any warning sensation just before coughing or laryngospasm begins? Yes No If yes, please circle any that apply:

-Sudden tickle -Sudden “dry patch” -Sudden burning -A jabbing or stabbing sensation

-A feeling of a “crumb caught in my throat” -Other: ___________________

LOCATION: _____________________________________

4) Are you aware of anything that triggers coughing / laryngospasm? Yes No

If yes, please circle all that apply:

-Talking -Laughing -Singing

-Breathing cold air -Breathing warm air -Touching a spot on my neck

-Eating -Swallowing -Posture change esp. at night

-Other___________________

…please underline the main trigger in the above list, if any

5) Please review the list of things that we’ve learned may happen to persons with severe coughing or laryngospasm. Please circle all that apply:

-I turn red -My eyes tear -My nose runs

-I almost throw up -I do throw up -I nearly pass out -I do pass out

-I have sudden intense difficulty breathing (laryngospasm)

-I lose urine -I have broken one or more ribs

-Other:______________________________

6) Estimated duration of a “major attack”: ________ # during day _____# during Sleep____

7) Estimated duration of a “lesser attack”: ________ # during day _____ # during Sleep____

8) On average, how many times do you experience laryngospasm? Day_____Night_____

NAME: _________________________________________

9) Most people with your problem say it is roughly the same week after week. Some, however, notice periods of greater or lesser severity. Which is the case for you? Please circle one of the following.

-Roughly the same since onset -Varies from week to week

-Varies from month to month -May have long periods relatively symptom free

10) If your cough / laryngospasm varies, is there any discernible pattern? Circle any that

apply.

-Worse for some time following upper respiratory infection

-Seems to be tied to the change of seasons

-Other __________________________________________

11) How many doctors do you think you have seen specifically for this problem? _________

12) How many in each of the following specialties? Please circle all that apply.

-Family Doctor _____ -Internist ____ -Pulmonologist _____ -Ear, Nose, Throat ___

-Psychiatrist _____ -Allergist ____ -Speech Pathologist

-Other ___________________________________________

13) What tests have you had for your problem? Please circle all that apply.

-Chest xray -CT scan -MRI -Pulmonary Function Tests

-Bronchoscopy -24-hour acid test -Esophagoscopy -Allergy tests

Were they all normal? Yes No

14) What are you told is the cause of your cough / laryngospasm? _______________________

15) Please indicate these medications you have tried, by name or type. Please circle or fill in as appropriate.

Asthma inhalers ________________ Acid reflux medication ____________________

Cough suppressant ______________ Antibiotics_____________________________

Expectorant ___________________ Topical anesthetic _______________________

Amitriptyline (Elavil) Gabapentin (Neurontin)

Oxcarbazepine (Trileptal) Other 1 __________________________

Other 2_________________________ Other 3 __________________________

16) Did any medication ever seem to help noticeably? Yes No If yes, which one(s)?

Medication: ___________________________ % reduction symptoms: _____________

Medication: ___________________________ % reduction symptoms: _____________

NAME: _________________________________________________________________________

17) Have you tried any other treatments for your problem? Yes No If yes, please circle any that apply.

Hypnosis Accupuncture Herbal remedies

Vitamins Other _________________________________

18) Did any of the above alternative treatments seem to help? Yes No

If yes, which one(s)?

19) Are you on currently or have you ever taken an ACE inhibitor generally used for blood

pressure control? Yes No If yes, please circle any that apply—the first list is

trade names, second is chemical name.

Accupril Aceon Altace Capoten

Lotensin Mavik Monopril Prinivil

Univasc Vasotec Zestril

Benazepril Captopril Cilazapril Enalapril

Enalaprilat Fosinopril Lisinopril Moexipril

Perindopril Quinapril Ramipril Trandolapril

20) In what ways has this problem affected you? Please circle all that apply.

a. It hasn’t—I just carry on and cope.

b. I limit talking.

c. I avoid public events when possible, for fear of making a disturbance with my coughing.

d. I sleep alone so as not to disturb my bed partner.

e. I have lost my job because of the coughing.

f. I’ve had to change jobs because of my coughing.

g. Other: _________________________________________________

21) On a scale of 1 to 7, where 1 represents a minor annoyance, 4 a medium, somewhat

difficult, but not terrible problem, and 7 a major problem that is “ruining your life,” how

would you rate your problem?

1 2 3 4 5 6 7

22) Is there anything else you would like to say about your problem?

PAST MEDICAL HISTORY

23) The following is a list of medical problems. Please circle any that apply, and describe.

High blood pressure _____________________ Heart disease _______________________

Diabetes _______________________________ Lung problems _____________________

Kidney disorders ______________________ Neurological problems _________________

NAME ____________________________________________________________________________

24) From the following list of types of surgeries: Please circle those that apply, and describe in the blanks.

Ear, Nose, Throat ______________________________________________

Chest ________________________________________________________

Abdomen _____________________________________________________

Orthopedic ____________________________________________________

Neurological ___________________________________________________

Other _________________________________________________________

25) Do you smoke? Yes No If yes, how many years? _______________

26) If you don’t smoke now, did you ever smoke? Yes No Years? __________

27) Alcohol consumption. Circle one. -daily -weekly -monthly -rarely -none

28) Please list the medications you are currently taking:

Medication: __________________________ Medication: _______________________

Medication: __________________________ Medication: _______________________

Medication: __________________________ Medication: _______________________

Medication: __________________________ Medication: _______________________

29) Please list any medications to which you are allergic: _____________________________

REVIEW OF SYSTEMS Please circle any of the following symptoms that apply.

Weight loss Fever/chills Hearing difficulty Vision disturbance

Breathing problem Chest pain Irregular heartbeat Dizziness

Nausea /vomiting Heartburn Acid belching Morning sore throat

Hoarseness Morning mucus Snoring Nighttime breathholding

Cold intolerance Arthritis Numbness or tingling Weakness

Skin problem Other: ________________________

FAMILY HISTORY Please fill in which family members have the following disorders.

Heart disease___________________________________________________________

Asthma _______________________________________________________________

Acid reflux or GERD ___________________________________________________

Coughing problem _____________________________________________________

Diabetes ______________________________________________________________

Cancer (specify type) ___________________________________________________

Neurological disorder __________________________________________________

Psychiatric disorder ___________________________________________________

Other _______________________________________________________________

______________________________________________________________

______________________________________________________________

END OF QUESTIONNAIRE—PLEASE STOP HERE

NAME: _____________________________________________________________________

EXAMINATION:

General: WDWN Distinguishing issues: _________________________________________

OC nl abnl ______________________________________________________

OP nl abnl ___________________________________________________________

HP nl abnl ___________________________________________________________

LX: nl abnl ___________________________ Inadequate visualization

Trachea: nl abnl ___________________________ Inadequate visualization

Lungs: nl abnl ___________________________________________________________

Procedure: Videoendoscopy Videostroboscopy Bronchoscopy VESS

Anesthesia: 2% Pontocaine to nose

Hurricaine to Oral Cavity, Oropharynx

4% lidocaine to larynx, trachea via Abraham Cannula

4% lidocaine via cricothyroid membrane puncture for tracheal anesthesia

4% lidocaine via existing tracheotomy tube

Sedation: no yes _____________________________________________________________

Scope: ENF-V videoendoscope

Wolf 90-degree telescope

PEF-V esophagoscope

Findings: normal abnormal

Abnormal : quivering asymmetry myoclonus hyperadduction phon.

Hyperadduction breathing tremor

Reflux findings mucosal disturbance ____________________

Other____________________________________________________

Impression: neuropathic cough nonorganic cough Drug-induced cough ________

Bronchitis Asthma-related Reflux cofactor

Plan: Reassurance only Speech Therapy Reflux med _______________

Asthma inhaler __________________________

Amitriptyline _______________________________________________________

Neurontin __________________________________________________________

Trileptal ___________________________________________________________

Followup: Phone to Physician Voicemail 1 week & F/U appt. 1 month

LETTER:

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