RESPIRATORY SYSTEM
I. Introduction
Name: Age: Sex: Handedness: Resident of:
Education: Occupation: Religion: Informant: Reliability:
II. Chief Complaints (in chronological order)
III. HOPI
1) Cough- Onset, Dry/Wet, Day/Night/ Postural/seasonal variation, associated
with, aggravated by / relieved by, present status
2) Expectoration- Color, Consistency, Quantity, Smell, Diurnal/ Postural variation,
More in the early morning, Aggravated by / Relieved by, Present status
3) Hemoptysis- Color, Quantity, Frequency, Postural variation, Associated with,
Last episode, Postural symptoms, Aggravated by / Relieved by, Present status
4) Dyspnoea- Onset, Progression (describe wrt activities), Associated with,
Aggravated by / Relieved by, Present status, MMRC grading (0-4), PND,
Orthopnoea
5) Wheeze- Duration , Periodicity, Seasonal/ Diurnal variation, Associated allergic
features like allergic rhinitis, urticaria, recurrent sneezing, Aggravated by /
Relieved by, Present status
6) Chest pain-( OLD CAARTS) Onset, Location, Duration, Character,
Associated features, Aggravating and Relieving factors, Radiation, Time, Severity
7) Fever- Grade, Max Temp, Type, Associated with chills& rigors, Diurnal
variation, Evening rise of temp., night sweats, relieved by, present status
8) Anorexia
9) Weight loss- Quantified/Unquantified, lntentional /Unintentional,
Significant/insignificant
10) Hoarseness of voice
11) Ptosis
12) Recurrent respiratory infection
13) History suggestive of Collagen Vascular Disease-Joint pain/rash/oral
ulcers/seizures/excessive hairfall
14) Palpitation /Easy fatiguability
15) Bladder / Bowel symptoms
16) Swelling of face/ edema
17) CNS symptoms-LOC/Head ache/weakness/vomiting
IV. Past History
DM/ HTN / TB/ Bronchial asthma/IHD
Childhood infection
Jaundice/ Blood Txn
Allergies/ FB inhalation
Trauma/ Surgeries/ similar illness in the past
V. Personal History
Smoking - pack years/smoking index/ Chula smoking
Alcohol / Tobacco
Veg / Non veg
Marital status/ Children/Menstrual history in detail
High risk behavior/Bladder/Bowel/Sleep
Immunization history
Socio-economic status/ over crowding
VI. Family history
TB/ Similar illness in the family
VII. Treatment history
VIII. Summary at the end of the history
IX. Impression/ DD
General physical examination
Conscious/oriented/comfortable
Ht- Weight- BMI- Temp-
Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F delay, Pulse
deficit, Vessel wall, Carotid bruit)
BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic / Thoraco-
Abdominal)
SpO2- BCG scar
P/J/Cy/Cl/LNE/PE/JVP/rash/facial plethora/neck veins/puffiness of face/ Pemberten
sign /Lt supra clavicular LN /Voice/asterixis
Signs of Malnutrition- Temporal / Buccal fat wasting, Hollowness of supraclavicular –
infraclavicular fossae, Emaciated look
Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies
Spine – Kyphosis / Scoliosis /Gibbus, Skull
Peripheral signs of TB / Sarcoid / HIV
Marfanoid features, Thyroid, Testes, Low hair line, Horners Features, Congenital
anomalies
Systemic Examination
Respiratory System:
Upper Respiratory Tract
Ear, Nose ( polyps, postnasal drip, DNS )
Throat ( tonsils, oral hygiene, nicotine stain )
Inspection
Chest symmetry, Pectus excavatum/ Carinatum
Shape of chest
Respiratory movements - equal / decreased
Tracheal position / Trail sign
Signs of volume loss – shoulder droop/wasting ( supra/infra clavicular)/Nipple position/
Spino scapular distance/ Rib crowding/ Intercostal spaces
Intercostal space indrawing / Hoover’s sign/Respiratory paradox/ Respiratory alternans
Accessary muscles of respiration
Apical impulse
Dilated veins/Scars/Sinuses/Visible pulsations/Skin
Palpation
Inspiratory findings confirmed
Tracheal position
Apical impulse
Rib crowding
Chest wall tenderness/ Crepitus / SC emphysema/ Nodules / LNE
Harrison’s sulcus / Hoover’s sign
Measurements
Chest Spino Antero-
Hemithorax Transverse
Circumferanc Expansion Hemithorax Scapular Posterior
expansion Diameter
e Distance Diameter
Right
Left
Supra Infra Infra Supra Inter Infra
Mammary Axillary
Clavicular clavicular Axillary Scapular Scapular Scapular
Respiratory Rt
Movement Lt
Percussi Rt
on Lt
Kronig’s Rt
Isthmus Lt
Percussion Rt
over
clavicle Lt
Percussion over Traube Space
Liver Dullness, Tidal Percussion
Auscultation
Supra Infra Infra Supra Inter Infra
Mammary Axillary
Clavicular clavicular Axillary Scapular Scapular Scapular
Rt
Air Entry
Lt
Rt
VF, VR
Lt
Rt
VBS
Lt
Bronchial Rt
Breathing Lt
Wheeze/ Rt
Rhonchi Lt
Rt
Crackles
Lt
Whispering
Pectroloquy
Aegophony
Pleural Rub
Cardio-Vascular System
Apical Impulse
Precardial buldge, Parasternal heave
Palpable sounds, Thrill
S1,S2,S3,S4
Murmurs
Abdomen
Symmetry/Distension
All quadrants moves with respiration
Soft, Tenderness, Liver, Spleen, Any mass, Bowel sounds, Hernial orifices
Central Nervous System
Consciousness,Orientation
FND, Horner’s Syndrome, Planters
Summary after Examination
Diagnosis/DD
Investigation
Treatment
