CASE TAKING PROFORMA - RESPIRATORY SYSTEM
Short Description
THIS PROFORMA IS DESIGNED TO MAKE THE MBBS STUDENTS TO UNDERSTAND WHAT ALL TO ASK A PATIENT WHEN TAKING AN EXAM CASE...
Description
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
o
Mode of onset
Solids/liquids
Progression
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( O 2 tetany)
Extra pyramidal symptoms(
Muscle twitching
Examination of Respiratory system General examination:
Comfortable
Conscious
Oriented
Built
Nourishment
O2 of basal ganglia)
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 c iliospinal 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
Vital signs:
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
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 o
o
Mammary
Axilla o
Axillary
o
Infra axillary
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 c ostal 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
o
o
Bronchovesicular breath sound
o
Absent breath sounds
Added sounds o
o
o
o
Amphoric
Crepitations/ crackles
Inspiratory/ expiratory / both phases
Fine/medium/coarse leathery
Change afer coughing
Ronchi/ wheeze
Inspiratory / expiratory both
Pitch
Monophonic / polyphonic
Change after coughing
o
Pleural rub
o
Post tussive suction
Vocal resonance o
Compare both sides
o
Bronchophony
o
Aegophony (E to A)
o
Whispering pectoriloquy
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)
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