Name/Age/sex/Occupation/address Name/Age/sex/Occupation/address Presenting Complaints:
Presenting Complaints:
History of presenting complaints: History of presenting complaints: Cough with expectoration: Cough with expectoration:
DurationDuration
Mode of onsetMode of onset
ParoxysmalParoxysmal
Dry / productiveDry / productive
Postural / diurnalPostural / diurnal
Aggravating / reliving factorsAggravating / reliving factors
Associated factors - chest Associated factors - chest pain, syncopepain, syncope
Sputum: Sputum:
Duration and mode of onsetDuration and mode of onset
QuantityQuantity
Colour and odourColour and odour
Character - mucoid /serous, purulent / Character - mucoid /serous, purulent / mucopurulentmucopurulent
With / without bloodWith / without blood
Postural and diurnal variationPostural and diurnal variation
Hemoptysis: Hemoptysis: DurationDuration EpisodesEpisodes
Fresh or altered bloodFresh or altered blood
Associated with purulent sputum or food particlesAssociated with purulent sputum or food particles
Breathlessness: Breathlessness: DurationDuration OnsetOnset GradeGrade ProgressionProgression
Aggravating/relieving factorsAggravating/relieving factors PND/orthopneaPND/orthopnea Chest pain: Chest pain: DurationDuration SiteSite
Mode of onsetMode of onset
Nature - pricking/stabbingNature - pricking/stabbing
RadiationRadiation
Postural variationPostural variation
Aggravating or relieving factorsAggravating or relieving factors
Associated with food intakeAssociated with food intake
Associated with nausea, vomitingAssociated with nausea, vomiting
Negative History: Negative History:
H/o wheeze(duration, diurnal variation, aggravating/relieving factors)H/o wheeze(duration, diurnal variation, aggravating/relieving factors)
H/o halitosisH/o halitosis
Symptoms of TB:Symptoms of TB: o
o H/o fever with evening rise of H/o fever with evening rise of temperaturetemperature o
o H/o loss of weightH/o loss of weight o
o H/o loss of appetiteH/o loss of appetite o
o H/o night sweatsH/o night sweats
Symptoms of cardiac involvementSymptoms of cardiac involvement o
o H/o pedal edemaH/o pedal edema o
o H/o abdominal distensionH/o abdominal distension o
o H/o right hypochondrial painH/o right hypochondrial pain o
o H/o puffiness of faceH/o puffiness of face o
o H/o palpitationH/o palpitation o
o H/o syncopeH/o syncope o
o H/o oliguriaH/o oliguria
Symptoms suggestive of malignancySymptoms suggestive of malignancy o
o H/o hoarsenessH/o hoarseness o
o H/o dysphagiaH/o dysphagia
Mode of onsetMode of onset
Solids/liquidsSolids/liquids
ProgressionProgression
o
o H/o loss of appetiteH/o loss of appetite
Past History: Past History:
H/o previous similar episodesH/o previous similar episodes
H/o HT/DMH/o HT/DM
H/o TBH/o TB o
o Any contactAny contact o
o AgeAge o
o Treatment - if incomplete - why?Treatment - if incomplete - why?
History suggestive of pneumoniaHistory suggestive of pneumonia o
o Aspiration(A - aspiration, B - Booze, C - coma, D Aspiration(A - aspiration, B - Booze, C - coma, D - Drowning, E - Epilepsy, F - Foreign- Drowning, E - Epilepsy, F - Foreign
body) body)
o
o Exanthematous feverExanthematous fever o
o Tooth, extraction, tonsillectomy, allergyTooth, extraction, tonsillectomy, allergy o
o TraumaTrauma o
History suggestive of PEHistory suggestive of PE o
o Acute abdominal distressAcute abdominal distress
(Subphrenic abscess, amoebic abscess, Pancreatitis) (Subphrenic abscess, amoebic abscess, Pancreatitis)
H/o past infectionsH/o past infections o
o Measles, Whooping coughMeasles, Whooping cough o
o Recurrent respiratory tract infectionsRecurrent respiratory tract infections
Family History: Family History:
ElaborateElaborate
Ask forAsk for o
o H/o TB/primary complexH/o TB/primary complex o
o H/o allergiesH/o allergies o
o H/o infertility/abortionsH/o infertility/abortions
Personal History: Personal History: SmokingSmoking AlcoholAlcohol DietDiet
Exposure - occupational, STD elaborationExposure - occupational, STD elaboration
Treatment history: Treatment history: Summary:
Summary:
Age/sex/name? Personal History? Family history? Presenting complaints?
Age/sex/name? Personal History? Family history? Presenting complaints? Other relevant positiveOther relevant positive findings findings System RS System RS Acute/ChronicAcute/Chronic Rt/Lt/BothRt/Lt/Both Parenchyma/pleura/airwayParenchyma/pleura/airway Obstructive/restrictiveObstructive/restrictive
Suppurative/non suppurativeSuppurative/non suppurative
EtiologyEtiology
With/without complications? Cor pulmonaleWith/without complications? Cor pulmonale
Obstructive lung diseases(Hypercarbia) Obstructive lung diseases(Hypercarbia)
Head acheHead ache
DrowsinessDrowsiness
Restrictive Lung disease Restrictive Lung disease
TachypneaTachypnea
Convulsions( OConvulsions( O22 tetany) tetany)
Extra Extra pyramidal pyramidal symptoms( symptoms( OO22 of basal ganglia) of basal ganglia)
Muscle twitchingMuscle twitching
Examination of Respiratory system Examination of Respiratory system General examination: General examination: ComfortableComfortable ConsciousConscious OrientedOriented BuiltBuilt NourishmentNourishment
Febrile/ afebrileFebrile/ afebrile
Pallor (Anemic/not anemic)Pallor (Anemic/not anemic) Icteric/notIcteric/not ClubbingClubbing CyanosisCyanosis
Pedal oedemaPedal oedema
Significant lymphadenopathySignificant lymphadenopathy
Conjunctival suffusionConjunctival suffusion
See for See for
IVC obstructionIVC obstruction
HalitosisHalitosis
HornerHorner’’s syndrome: Ptosis, anhydrosis, miosis, enophthalmos, loss of cs syndrome: Ptosis, anhydrosis, miosis, enophthalmos, loss of c iliospinal reflexiliospinal reflex
TroiserTroiser’’s sign: Enlargement of Lt. supraclavicular lymph nodes sign: Enlargement of Lt. supraclavicular lymph node
Markers of pulmonary malignancy:Markers of pulmonary malignancy: o
o Acanthosis nigricansAcanthosis nigricans o
o GynaecomastiaGynaecomastia o
o Clubbing, HPOAClubbing, HPOA
Markers of sarcoidosis:Markers of sarcoidosis: o
o Hilar, mediastinal lymph node enlargementHilar, mediastinal lymph node enlargement o
o Tonsillar enlargementTonsillar enlargement o
o HepatospleenomegalyHepatospleenomegaly o
o Eye: iritis, iridocyclitis, choroid retinitisEye: iritis, iridocyclitis, choroid retinitis o
o Skin: SC nodules, erythematous plaques, Erythema nodosumSkin: SC nodules, erythematous plaques, Erythema nodosum o
o ParotitisParotitis o
o Nasal polypsNasal polyps o
o Joint painJoint pain
Markers Markers of of TB:TB: o
o Phlycten, choroids, tuberclesPhlycten, choroids, tubercles o
o Scars/sinuses in the neckScars/sinuses in the neck o
o Scrofula - SC lymphadenitis in neckScrofula - SC lymphadenitis in neck o
o Lupus vulgarisLupus vulgaris o
o Erythema nodosumErythema nodosum o
o Cold abscess/ collar stud abscessCold abscess/ collar stud abscess o
o Tinea versicolorTinea versicolor o
o Gynaecomastia - INH (bronchogenic CA)Gynaecomastia - INH (bronchogenic CA)
Markers of HIVMarkers of HIV o
o Hairy LeucoplakiaHairy Leucoplakia o
o Oral candidiasisOral candidiasis o
o Molluscum contagiosumMolluscum contagiosum o
o Premature greying of hairPremature greying of hair o
o Long eye lashes(trichomegaly)Long eye lashes(trichomegaly) o
o Herpetic infectionsHerpetic infections o
o Generalised lymphadenopathyGeneralised lymphadenopathy
Vital signs: Vital signs:
Pulse rate: elaborate (expect pulsus paradoxus)Pulse rate: elaborate (expect pulsus paradoxus)
BP:BP:……….. mm Hg.. mm Hg………..limbs..limbs………postureposture
Respiratory rate, rhythm, typeRespiratory rate, rhythm, type
TemperatureTemperature
JVPJVP
Systemic examination of Respiratory system: Systemic examination of Respiratory system: 1. Inspection:
1. Inspection:
Upper respiratory tractUpper respiratory tract o
o Nasal septumNasal septum o
o Sinus tendernessSinus tenderness o
o PolypsPolyps o
o TonsilsTonsils o
o Oral hygieneOral hygiene o
o HalitosisHalitosis o
o Post nasal dripPost nasal drip
ChestChest o
o SymmetrySymmetry o
o Shape - flat, barrel Shape - flat, barrel chest(emphysema, pigeon chest, funnel chest (marfan syndrome)chest(emphysema, pigeon chest, funnel chest (marfan syndrome) o
o Costochondral bending ( Rachitic rosary), Scorbutic rosaryCostochondral bending ( Rachitic rosary), Scorbutic rosary o
o Movement with respirationMovement with respiration o
o Scars, IC fullness, IC indrawing, crowding of ribs, discharging sinuses(TB)Scars, IC fullness, IC indrawing, crowding of ribs, discharging sinuses(TB) o
o Tracheal position with TrailTracheal position with Trail’’s signs sign o
o Apical impulseApical impulse o
o Drooping of shouldersDrooping of shoulders o
o Supraclavicular Supraclavicular and IC and IC hallowinghallowing o
o HarrisonHarrison’’s sulcuss sulcus o
o Prominence of medial border of scapulaProminence of medial border of scapula o
o KyphoscoliosisKyphoscoliosis o
o Dilated veins over chest, tracheal movement during inspirationDilated veins over chest, tracheal movement during inspiration
2. Palpation: 2. Palpation:
o
o Tracheal positionTracheal position o
o Apical impulseApical impulse o
o AP diameterAP diameter o
o Transverse diameterTransverse diameter o
o RatioRatio o
o Chest movement by palpationChest movement by palpation o
o Chest expansion measurement - bilateral and hemi thoraxChest expansion measurement - bilateral and hemi thorax o
o Tactile fremitus, IC tendernessTactile fremitus, IC tenderness o
o Vocal fremitusVocal fremitus o
o Lymph nodes - Cervical, Supraaxillary, axillary, ScaleneLymph nodes - Cervical, Supraaxillary, axillary, Scalene
3. Percussion 3. Percussion
o
o Directly on clavicleDirectly on clavicle o
o AnteriorlyAnteriorly o
o Supraclavicular (apex)Supraclavicular (apex) o
o o MammaryMammary o o AxillaAxilla o o AxillaryAxillary o
o Infra axillaryInfra axillary o o PosteriorPosterior o o SuprascapularSuprascapular o o InfrascapularInfrascapular o o InterscapularInterscapular UpperUpper MiddleMiddle LowerLower o
o Tidal percussionTidal percussion o
o TraubeTraube’’s space - left sixth rib, the left axillary line and the left cs space - left sixth rib, the left axillary line and the left c ostal marginostal margin o
o Shifting dullness, straightline dullnessShifting dullness, straightline dullness
4. Auscultation: 4. Auscultation:
o
o Auscultation in above areasAuscultation in above areas o
o Breath soundsBreath sounds o
o Normal vesicular breath sound(harsh / normal)Normal vesicular breath sound(harsh / normal) o
o Bronchial breath soundBronchial breath sound
Pitch tubularPitch tubular
Pitch cavernousPitch cavernous
AmphoricAmphoric
o
o Bronchovesicular breath soundBronchovesicular breath sound o
o Absent breath soundsAbsent breath sounds o
o Added soundsAdded sounds o
o Crepitations/ cracklesCrepitations/ crackles
Inspiratory/ expiratory / both phasesInspiratory/ expiratory / both phases
Fine/medium/coarse leatheryFine/medium/coarse leathery
Change afer coughingChange afer coughing
o
o Ronchi/ wheezeRonchi/ wheeze
Inspiratory / expiratory bothInspiratory / expiratory both
PitchPitch
Monophonic / polyphonicMonophonic / polyphonic
Change after coughingChange after coughing
o
o Pleural rubPleural rub o
o Post tussive suctionPost tussive suction o
o Vocal resonanceVocal resonance o
o Compare both sidesCompare both sides o
o BronchophonyBronchophony o
o Aegophony (E to A)Aegophony (E to A) o
o Whispering pectoriloquyWhispering pectoriloquy o
o OthersOthers o
o Succession splashSuccession splash o
Other systems: Other systems:
CVS : see for RHF, CCF CVS : see for RHF, CCF
Abdomen: see for liver abscess
Abdomen: see for liver abscess - tenderness- tenderness CNS: see for asterexis
CNS: see for asterexis Diagnosis:
Diagnosis:
………
……….sided.sided………..disease(PE/fibrosis) probably due to..disease(PE/fibrosis) probably due to ………
