OM SAKTHI

MELMARUVATHUR ADHIPARASAKTHI INSTITUTE OF MEDICAL SCIENCE & RESEARCH

MELMARUVATHUR – 603319

GENERAL MEDICINE DEPARTMENT

Respiratory System

Basic Data:

Chief complaints:

Presenting Complaints:

History of presenting complaints:

Cough :

 Duration
 Mode of onset
 Paroxysmal
 Dry / productive
 Postural / diurnal / Seasonal
 Aggravating / relieving 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 / Seasonal /diurnal

variations

Hemoptysis:

 Duration
 Episodes
  Fresh or altered blood
 Associated with purulent sputum or food particles

Dyspnoea:

 Duration
 Onset
 Grade
 Progression
 Aggravating/relieving factors
 PND/orthopnea

 Associated wheeze

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

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, choroid 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 after 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 Succussion splash
o Coin test
o Other systems:
o CVS : see for RHF, CCF
o Abdomen: see for liver abscess - tenderness CNS:
see for asterexis

Diagnosis:
o …………………….sided..................... disease(PE/fibrosis) probably due to
o ……………………(with / without signs of RHF)
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