Name / Age / Sex / Occupation / Address
Chief Complaints:
History of presenting illness:
H/o Cough with expectoration
Duration
Mode of onset
Paroxysmal
Dry / productive
Postural / Diurnal variation
Aggravating factors
Relieving factors
Associated factors – chest pain, syncope
H/o Sputum
Duration
Colour and odour
Amount
Character – mucoid/serous, purulent,mucopurulent
With/without blood
Postural / Diurnal variation
H/o Hemoptysis
Duration
Episodes
Amount of blood
Fresh or altered blood
Associated with purulent sputum or food particles
H/o Breathlessness
Duration
Onset
Minutes
• Pulmonary thromboembolism
• Pneumothorax
• Asthma
• Inhaled foreign body
• Acute left ventricular failure
Hours to days
• Pneumonia
• Asthma
• Exacerbation of COPD
Weeks to months
• Anemia
• Pleural effusion
• Respiratory neuromuscular disorders
Months to years
• COPD
• Pulmonary fibrosis
• Pulmonary tuberculosis
Grade
Medical Research Council (MRC) breathlessness scale
Grade 1 Breathless when hurrying on the level or walking up a
slight hill
Grade 2 Breathlessness when walking with people of own age or
on level ground
Grade 3 Walks slower than peers, or stops when walking on the
flat at own pace
Grade 4 Stops after walking 100 meters, or a few minutes, on the
level
Grade 5 Too breathless to leave the house
(Grade 5b) Too breathless to wash or dress
Progression
Aggravating factors
Relieving factors
Postural variation
Orthopnea
Paroxysmal nocturnal dyspnea
Trepopnoea
Platypnoea
Timing of the day – Myasthenia gravis, COPD, bronchial asthma, cardiac failure
H/o Chest pain
Duration
Site
Mode of onset
Nature/ Character – pricking /stabbing
Grade / severity
Radiation
Postural variation
Changes with respiration
Diurnal variation
Aggravating factors
Relieving factors
Associated with food intake
Associated with nausea sweating
Associated with other symptoms
H/o Wheeze
Duration
Onset
Diurnal variation
Aggravating factors
Relieving factors
H/o Halitosis
H/o Fever with evening rise of temperature
H/o Loss of weight
H/o Loss of appetite
H/o Night sweats
H/o Pedal edema
H/o Abdomen distension
H/o Right hypochondrial pain
H/o Facial puffinenss
H/o Palpitations
H/o Syncope
H/o Oliguria
H/o Abdomen tenderness
H/o Hoarseness of voice
H/o Dysphagia
Mode of onset
Duration
Progression
Solids/liquids
PAST HISTORY
H/o similar episodes in the past
H/o BA / any known allergies
H/o HTN/DM/CAD/Epilepsy
H/o PTB
Any contact /age / treatment if any
H/o Pneumonia
Aspiration
Exanthemous fever
Tooth extraction, tonsillectomy,
H/o Trauma
H/o Exposure to STDS
H/o pulmonary embolism
Acute abdominal distress
Subphrenic abscess / amoebic liver abscess / pancreatitis
H/o Past infections
Measles, whooping cough, recurrent resp tract infections
TREATMENT HISTORY
H/o ATT drugs
H/o ACE inhibitors use
H/o treatment for other systemic illnesses
FAMILY HISTORY
H/o PTB in other family members
H/o known allergies in family members
H/o other systemic illnesses
PERSONAL HISTORY
Smoking in pack years
Alcohol
Betel nut / tobacco abuse
Diet
Sleep habits / bowel and bladder habits
SOCIAL HISTORY / MENSTRUAL HISTORY
Menstrual history / menopausal history
H/o contact with STDs
SUMMARY
EXAMINATION OF THE RESPIRATORY SYSTEM
GENERAL EXAMINATION
Conscious
Oriented
Afebrile / febrile
Comfortable / dyspnoeic at rest
Built / nourishment
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal edema
Others:
IVC obstruction
Halitosis
Horners syndrome
Troisers sign
Markers of pulmonary malignancy
Acanthosis nigricans
Gynaecomastia
Clubbing / HPOA
Markers of sarcoidosis
Tonsillar enlargement
Hepato splenomegaly
Eye: iritis, iridocyclitis, choroid retinitis
Skin: SC nodules, erythematous plaques, erythema nodosum
Parotitis
Nasal polyps
Markers of TB
Phlycten, choroids, tubercles
Scars / sinuses in the neck
Scrofula – s/c lymphadenitis in the neck
Lupus vulgaris
Erythema nodosum
Cold abscess / collar stud abscess
Tinea versicolor
Gynaecomastia – INH / bronchogenic Ca
Markers of HIV
Hairy leukoplakia
Oral candidiasis
Molluscum contagiosum
Premature greying of hair
Long eye lashes [trichomegaly]
Herpetic infections
Generalized lymphadenopathy
VITAL SIGNS
PULSE
Rate / rhythm / character / volume / condition of the vessel wall
Felt in all peripheral vessels
Radio radial / radio femoral delay
BLOOD PRESSURE
Mm of hg / limb / posture
RESPIRATION
Rate /rhythm / type
TEMPERATURE
JUGULAR VENOUS PULSE
EXAMINATION OF THE RESPIRATORY SYSTEM
INSPECTION
UPPER RESPIRATORY TRACT
Nasal septum
Sinus tenderness
Polyps
Tonsils
Oral hygiene
Halitosis
Post nasal drip
CHEST
Symmetry
Shape –
Normal
Long flat chest
Alar chest [pterygoid chest/winged chest}
Pigeon chest / chicken breast / pectus carinatum /keel chest
Rachitic chest
Barrel chest
Funnel chest / pectus excavatum / cobblers breast
[s/I marfan syndrome, straight back syndrome}
Phthinoid chest [pre tuberculous chest, paralytic thorax}
Visceroptic chest
Gutter breast
Fissured chest
Scaphoid chest
Scorbutic rosary
Flail chest / stove in chest
Shield chest [s/I Turners, Noonan’s syndrome}
Bilaterally contracted chest
Bilaterally expanded chest
Costochondral bending – rachitic rosary / scorbutic rosary
Movement with respiration
Tracheal position with trail sign
Tracheal movement during inspiration
Apical impulse
Scars / sinuses / discharging sinuses
IC fullness / IC tenderness
Drooping of shoulders
Supraclavicular and infraclavicular hollowing
Harrison’s sulcus
Prominence of medial border of the scapula
Use of accessory muscles of respiration
Kyphoscoliosis
Dilated veins over the chest
PALPATION
Tracheal position
Tracheal tug
Apical impulse
AP diameter
Transverse diameter
Ratio
Chest Expansion
Chest Movements
Anterior Thoracic Movement
Posterior Thoracic Movement
Upper Thoracic Movement
Tenderness over the Chest Wall
Vocal Fremitus
Intercostal tenderness
PERCUSSION
Areas
Anterior Chest Wall
Clavicle
Supraclavicular region
Infraclavicular
Mammary
Lateral Chest Wall
Posterior Chest Wall
Suprascapular
Interscapular region
Infrascapular region
Tidal Percussion
Traube’s Space percussion
Straight Line Dullness
Shifting Dullness
AUSCULTATION
Vesicular breath sounds
Bronchial breath sounds
Tubular
Cavernous
Amphoric
Bronchovesicular breath sounds
Absent breath sounds
Added sounds
Crepitations / crackles
Inspiratory / expiratory / both phases
Fine / medium / coarse leathery
Change after coughing
Ronchi /wheeze
Inspiratory /expiratory
Pitch
Monophonic /polyphonic
Pleural rub
Post tussive suction
Vocal resonance
Compare both sides
Bronchophony
Aegophony
Whispering pectoriloquy
Others
Succusion splash
Coin test
Stridor
DIAGNOSIS
Acute / chronic
Parenchymal / interstitial / airway / extra pulmonary
[Lung] disease
Side
Structure / areas of the lung involved
Disease process – fibrosis /collapse / cavity /consolidation / effusion
Etiology
With or without signs of right heart failure
With or without skeletal deformities
And other features
