Case Taking Proforma - Respiratory System k4m73

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

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Radiation Postural variation Aggravating or relieving factors Associated with food intake Associated with nausea, vomiting

Negative History:   

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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:   

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H/o previous similar episodes H/o HT/DM H/o TB o Any 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

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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

        See for     

Febrile/ afebrile Pallor (Anemic/not anemic) Icteric/not Clubbing Cyanosis Pedal oedema Significant lymphadenopathy Conjunctival suffusion

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 t 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)