Name/Age/sex/Occupation/address

Presenting Complaints:

History of presenting complaints:

Cough with expectoration:

Duration

Mode of onset

Paroxysmal

Dry / productive

Postural / diurnal

Aggravating / reliving factors

Associated factors - chest pain, syncope

Sputum:

Duration and mode of onset

Quantity

Colour and odour

Character - mucoid /serous, purulent / mucopurulent

With / without blood

Postural and diurnal variation

Hemoptysis:

Duration

Episodes

Fresh or altered blood

Associated with purulent sputum or food particles

Breathlessness:

Duration

Onset

Grade

Progression

Aggravating/relieving factors

PND/orthopnea

Chest pain:

Duration

Site

Mode of onset

Nature - pricking/stabbing

Severity

Radiation

Postural variation

Aggravating or relieving factors

Associated with food intake

Associated with nausea, vomiting

Negative History:

H/o wheeze(duration, diurnal variation, aggravating/relieving factors)

H/o halitosis

Symptoms of TB:

o H/o fever with evening rise of temperature

o H/o loss of weight

o H/o loss of appetite

o H/o night sweats

Symptoms of cardiac involvement

o H/o pedal edema

o H/o abdominal distension

o H/o right hypochondrial pain

o H/o puffiness of face

o H/o palpitation

o H/o syncope

o H/o oliguria

Symptoms suggestive of malignancy

o H/o hoarseness

o H/o dysphagia

Mode of onset

Solids/liquids

Progression

o H/o loss of appetite

Past History:

H/o previous similar episodes

H/o HT/DM

H/o TB

o Any contact

o Age

o Treatment - if incomplete - why?

History suggestive of pneumonia

o Aspiration(A - aspiration, B - Booze, C - coma, D - Drowning, E - Epilepsy, F - Foreign

body)

o Exanthematous fever

o Tooth, extraction, tonsillectomy, allergy

o Trauma

o Exposure to STDs

History suggestive of PE

o Acute abdominal distress

(Subphrenic abscess, amoebic abscess, Pancreatitis)

H/o past infections

o Measles, Whooping cough

o Recurrent respiratory tract infections

Family History:

Elaborate

Ask for

o H/o TB/primary complex

o H/o allergies

o H/o infertility/abortions

Personal History:

Smoking

Alcohol

Diet

Exposure - occupational, STD elaboration

Treatment history:

Summary:

Age/sex/name? Personal History? Family history? Presenting complaints? Other relevant positive

findings

System RS

Acute/Chronic

Rt/Lt/Both

Parenchyma/pleura/airway

Obstructive/restrictive

Suppurative/non suppurative

Etiology

With/without complications? Cor pulmonale

Obstructive lung diseases(Hypercarbia)

Head ache

Drowsiness

Restrictive Lung disease

Tachypnea

Convulsions( O2 tetany)

Extra pyramidal symptoms( O2 of basal ganglia)

Muscle twitching

Examination of Respiratory system

General examination:

Comfortable

Conscious

Oriented

Built

Nourishment

Febrile/ afebrile

Pallor (Anemic/not anemic)

Icteric/not

Clubbing

Cyanosis

Pedal oedema

Significant lymphadenopathy

Conjunctival suffusion

See for

IVC obstruction

Halitosis

Horner’s syndrome: Ptosis, anhydrosis, miosis, enophthalmos, loss of ciliospinal reflex

Troiser’s sign: Enlargement of Lt. supraclavicular lymph node

Markers of pulmonary malignancy:

o Acanthosis nigricans

o Gynaecomastia

o Clubbing, HPOA

Markers of sarcoidosis:

o Hilar, mediastinal lymph node enlargement

o Tonsillar enlargement

o Hepatospleenomegaly

o Eye: iritis, iridocyclitis, choroid retinitis

o Skin: SC nodules, erythematous plaques, Erythema nodosum

o Parotitis

o Nasal polyps

o Joint pain

Markers of TB:

o Phlycten, choroids, tubercles

o Scars/sinuses in the neck

o Scrofula - SC lymphadenitis in neck

o Lupus vulgaris

o Erythema nodosum

o Cold abscess/ collar stud abscess

o Tinea versicolor

o Gynaecomastia - INH (bronchogenic CA)

Markers of HIV

o Hairy Leucoplakia

o Oral candidiasis

o Molluscum contagiosum

o Premature greying of hair

o Long eye lashes(trichomegaly)

o Herpetic infections

o Generalised lymphadenopathy

Vital signs:

Pulse rate: elaborate (expect pulsus paradoxus)

BP: ………….. mm Hg …………..limbs……………posture

Respiratory rate, rhythm, type

Temperature

JVP

Systemic examination of Respiratory system:

1. Inspection:

Upper respiratory tract

o Nasal septum

o Sinus tenderness

o Polyps

o Tonsils

o Oral hygiene

o Halitosis

o Post nasal drip

Chest

o Symmetry

o Shape - flat, barrel chest(emphysema, pigeon chest, funnel chest (marfan syndrome)

o Costochondral bending ( Rachitic rosary), Scorbutic rosary

o Movement with respiration

o Scars, IC fullness, IC indrawing, crowding of ribs, discharging sinuses(TB)

o Tracheal position with Trail’s sign

o Apical impulse

o Drooping of shoulders

o Supraclavicular and IC hallowing

o Harrison’s sulcus

o Prominence of medial border of scapula

o Kyphoscoliosis

o Dilated veins over chest, tracheal movement during inspiration

2. Palpation:

o Tracheal position

o Apical impulse

o AP diameter

o Transverse diameter

o Ratio

o Chest movement by palpation

o Chest expansion measurement - bilateral and hemi thorax

o Tactile fremitus, IC tenderness

o Vocal fremitus

o Lymph nodes - Cervical, Supraaxillary, axillary, Scalene

3. Percussion

o Directly on clavicle

o Anteriorly

o Supraclavicular (apex)

o Infraclavicular

o Mammary

o Axilla

o Axillary

o Infra axillary

o Posterior

o Suprascapular

o Infrascapular

o Interscapular

Upper

Middle

Lower

o Tidal percussion

o Traube’s space - left sixth rib, the left axillary line and the left costal margin

o Shifting dullness, straightline dullness

4. Auscultation:

o Auscultation in above areas

o Breath sounds

o Normal vesicular breath sound(harsh / normal)

o Bronchial breath sound

Pitch tubular

Pitch cavernous

Amphoric

o Bronchovesicular breath sound

o Absent breath sounds

o Added sounds

o Crepitations/ crackles

Inspiratory/ expiratory / both phases

Fine/medium/coarse leathery

Change afer coughing

o Ronchi/ wheeze

Inspiratory / expiratory both

Pitch

Monophonic / polyphonic

Change after coughing

o Pleural rub

o Post tussive suction

o Vocal resonance

o Compare both sides

o Bronchophony

o Aegophony (E to A)

o Whispering pectoriloquy

o Others

o Succession splash

o Coin test

Other systems:

CVS : see for RHF, CCF

Abdomen: see for liver abscess - tenderness

CNS: see for asterexis

Diagnosis:

…………………….sided……………………..disease(PE/fibrosis) probably due to

……………………(with / without signs of RHF)