Duration

Onset

Grade

Progression

Aggravating factors

Relieving factors

Orthopnea

Trepopnea

Platypnea

Paroxysmal nocturnal dyspnea (PND)

Any respiratory system complaints

Wheeze

Cough with expectoration

Chest pain:

Duration

Onset

Site

Type of pain

Radiation

Diurnal variation (nocturnal angina)

Variation with respiration

Aggravating factors

Relieving factors

Associated symptoms

Nausea, vomiting, sweating

Dyspepsia

Local tenderness

Wheeze:

Duration

Onset

Progression

Episodic or continuous

Variation

Allergy

Skin rashes

Aggravating and relieving factors

Fever:

Episodic or continuous

Grade

Chill and rigors

Aggravating factors

Relieving factors

Variation

Diurnal variation

History of:

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Nasal discharge

Recurrent cold/epistaxis

Recurrent headaches

Weight loss

Anorexia

Evening rise of temperature

Smoking

Belching

Regurgitation of food

Hoarseness of voice

Past history:

Asthma

Chronic obstructive airway disease

Tuberculosis

History of contact with tuberculosis

Diabetes mellitus (DM)

Hypertension (HTN)

Ischemic heart disease (IHD)

Seizure disorder

Family history:

(draw pedigree chart representing three generations as discussed in the chapter 15)

Personal history:

Bowel habits

Bladder habits

Appetite

Loss of weight

Occupational exposure

Sleep

Dietary habits and taboo

Food allergies

Smoking (in smoking Index or Pack years)

Alcohol history (__ grams of alcohol/day or ___ units of alcohol/week)

Menstrual and obstetric history

G__P__L__A__

Age of menarche __

Menopause at __

Flow—amenorrhea/oligomenorrhea/menorrhagia

Summarize:

Differential diagnosis:

GENERAL EXAMINATION

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Conscious

Cooperative

Obeying commands

BMI

W (kg)/H2

(m)

Grading according to WHO for Southeast Asian countries

Vitals

Pulse

Rate

Rhythm

Volume

Character

Vessel wall thickening

Radio-radial delay and radio femoral delay

Peripheral pulses

Blood pressure

Right arm

Left arm

Right leg

Left leg

Respiratory rate

Regular

Abdominothoracic (male) or thoracoabdominal (female)

Usage of accessory muscles

Jugular venous pulse

Waveform

Jugular venous pressure

__ cm of blood above sternal angle (+ 5 cm water)

Pulse oximetry

Pain

On physical examination

Pallor:

Icterus:

Cyanosis:

Clubbing:

Lymphadenopathy:

Edema:

Others head to toe:

Oral cavity examination

Use of accessory muscles of respiration

External markers of tuberculosis

External markers of malignancy

Features suggesting type of respiratory failure

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SYSTEMIC EXAMINATION

Upper Respiratory Tract Examination

Nostrils:

Nasal septum:

Nasal polyps:

Sinus tenderness:

Tonsils:

Post-pharyngeal wall:

Lower Respiratory Tract Examination

Inspection

Shape and symmetry:

Spine:

Sub costal angle:

Trachea:

Apex beat:

Respiratory movements:

Area Right Left

Upper anterior chest

Lower anterior chest

Upper posterior chest

Lower posterior chest

Visible pulsations/sinus/scars:

Palpation

(warm the palms by rubbing against each other before palpation)

Spine: Position and tenderness

Trachea:

Apex:

Respiratory movements:

Area Right Left

Supraclavicular

Infraclavicular

Mammary

Suprascapular

Infrascapular

Dimensions/Measurements

T diameter

AP diameter

T: AP diameter

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Inspiration

Right hemithorax Expiration

Inspiration

Left hemithorax Expiration

Inspiration

Chest expansion Right hemithorax

Left hemithorax

Total

Spinoscapular distance (Right side) and (left side)

Spinoacromial distance (Right side) and (left side)

Vocal fremitus:

Areas Right Left

Supraclavicular

Clavicular

Infraclavicular

Mammary

Axillary

Infra-axillary

Suprascapular

Interscapular

Infrascapular

Tactile fremitus:

Friction fremitus:

Tenderness:

Subcutaneous emphysema:

Rib crowding:

Bony tenderness:

Percussion

Areas Right Left

Supraclavicular

Clavicular

Infraclavicular

Mammary

Axillary

Infra-axillary

Suprascapular

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Infrascapular

Shifting dullness:

Tidal percussion:

Traube’s space:

Kronig’s isthmus:

Liver dullness:

Liver span:

Heart border on:

Right side:

Left side:

Auscultation

Breath sounds:

Vesicular/bronchovesicular/bronchial (tubular/cavernous/amphoric)

Comment on intensity of breath sound—normal/increased/decreased

Areas Right Left

Supraclavicular

Clavicular

Infraclavicular

Mammary

Axillary

Infra-axillary

Suprascapular

Interscapular

Infrascapular

Vocal resonance:

Areas Right Left

Supraclavicular

Clavicular

Infraclavicular

Mammary

Axillary

Infra-axillary

Suprascapular

Interscapular

Infrascapular

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Adventitious sounds:

Crepitations

Rhonchi (inspiratory or expiratory/polymorphic or monomorphic)

Rubs

Additional tests:

Coin test:

Bronchophony:

Egophony:

Whispered pectoriloquy:

Succussion splash:

Post-tussive crepts:

Other Systems

Cardiovascular system:

Inspection:

Palpation:

Percussion:

Auscultation:

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation :

Nervous system:

Higher mental functions:

Cranial nerves:

Sensory system:

Motor system:

Reflexes:

Cerebellar system:

Meningeal signs:

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B. DIAGNOSIS FORMAT

ANATOMICAL DIAGNOSIS

Lung (right/left/bilateral) disease with (upper/middle/lower) lobe

Pleural disease

PATHOLOGICAL DIAGNOSIS

Consolidation/fibrosis/collapse/obstructive lung disease/restrictive lung disease/effusion/pneumothorax.

ETIOLOGICAL DIAGNOSIS

Tuberculosis/bronchogenic carcinoma/smoking/occupation/trauma.

COMPLICATIONS

Respiratory failure (type I or type II)/corpulmonale.

EXAMPLES

Example 1

Right upper lobe fibrosis post-tubercular etiology, no evidence of respiratory failure or corpulmonale.

Example 2

Bilateral obstructive lung disease—emphysema secondary to smoking with evidence of type 2

respiratory failure and corpulmonale.

Example 3

Left-sided pleural effusion secondary to malignancy with no evidence of respiratory failure or

corpulmonale.

NOTES

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C. DISCUSSION ON CARDINAL SYMPTOMS

Symptoms discussed include:

Cough

Expectoration

Hemoptysis

Dyspnea

Chest pain (with respect to respiratory system)

Others

COUGH

Definition: A sudden and variable expiratory thrust of air from the lungs through the air passages

associated with phonation, which momentarily interrupts the physiological pattern of breathing.

Mechanism of cough production: Cough reflex initiated by chemical/mechanical stimuli (Flowchart

3C.1). This is carried by the afferents which are type C and type 1 fibers and innervate pharynx, larynx,

large airways, terminal bronchiole and lung parenchyma. Afferents travel via vagus and superior

laryngeal nerve. Nucleus tractus solitarius (NTS) in brainstem is the cough center. Efferents travel via

vagus, phrenic, spinal motor nerves to the larynx, trachea, bronchi, diaphragm producing cough.

Mechanical events during cough production: The mechanical events involved in a typical cough are

rapid successions of:

A fairly deep initial inspiration

The tight closure of the glottis, reinforced by the supraglottic structures

The quick and forceful contraction of the expiratory muscles

The sudden opening of the glottis while the contraction of the expiratory muscles continues.

Classification

Based on etiology: The etiology can be classified into respiratory causes and non-respiratory

causes.

Based on duration of cough: Cough has been classified into acute (less than 3 weeks), subacute

(3–8 weeks), and chronic (more than 8 weeks; Box 3C.1).

Box 3C.1: Chronic cough with normal chest X-ray.

Cough variant asthma

Tropical eosinophilia

Upper airway cough syndrome

Aspiration

Habitual cough

Foreign body

Drugs, angiotensin converting enzyme inhibitors

Chronic bronchitis

Chronic idiopathic cough

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