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    Respitatory System Case Proforma

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    prabhakaran payam
    Raju, a 7-year old boy, presented with fever, cough, difficulty breathing, and chest pain. His mother reported details of his cough, sputum production, breathlessness, chest pain, and past medical history. On examination, the physician assessed Raju's vital signs, inspected his respiratory system, palpated his chest, performed percussion and auscultation of his lungs, and examined other body systems. The physician documented findings to make a diagnosis.

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    Respitatory System Case Proforma

    Uploaded by

    prabhakaran payam
    648 views5 pages
    Raju, a 7-year old boy, presented with fever, cough, difficulty breathing, and chest pain. His mother reported details of his cough, sputum production, breathlessness, chest pain, and past medical history. On examination, the physician assessed Raju's vital signs, inspected his respiratory system, palpated his chest, performed percussion and auscultation of his lungs, and examined other body systems. The physician documented findings to make a diagnosis.

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    Respitatory System Case Proforma

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    Raju, a 7-year old boy, presented with fever, cough, difficulty breathing, and chest pain. His mother reported details of his cough, sputum production, breathlessness, chest pain, and past medical history. On examination, the physician assessed Raju's vital signs, inspected his respiratory system, palpated his chest, performed percussion and auscultation of his lungs, and examined other body systems. The physician documented findings to make a diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    648 views5 pages

    Respitatory System Case Proforma

    Uploaded by

    prabhakaran payam
    Raju, a 7-year old boy, presented with fever, cough, difficulty breathing, and chest pain. His mother reported details of his cough, sputum production, breathlessness, chest pain, and past medical history. On examination, the physician assessed Raju's vital signs, inspected his respiratory system, palpated his chest, performed percussion and auscultation of his lungs, and examined other body systems. The physician documented findings to make a diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    RESPIRATORY SYSTEM CASE SHEET

    Informant : mother (reliable)

    Raju, a 7 year old male child was bought by his mother with chief complaints of

    Presenting Complaints:
     Fever
     Cough and cold
     Rapid breathing/chest retractions or difficulty in breathing/noisy breathing
     Chest pain

    History of presenting complaints:

    Cough with expectoration:

    o Duration
    o Mode of onset
    o progression
    o Dry / productive
    o Postural / diurnal
    o Aggravating / reliving factors
    o 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
     Diurnal/seasonal variation
     Aggravating/relieving factors
    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 drug usage
     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 H/o loss of appetite

    Past History:

     H/o previous similar episodes


     H/o TB contact
     History suggestive of pneumonia
    o Aspiration
    o Exanthematous fever
    o Tooth, extraction, tonsillectomy, allergy
     H/o past infections
    o Measles, Whooping cough
    o Recurrent respiratory tract infections
    Birth history
    Antenatal
    Natal
    Postnatal

    Family History:
     pedigree chart
     Ask for
    o H/o TB/primary complex
    o H/o allergies

    Examination of Respiratory system

    General examination:
     Comfortable
     Conscious
     Oriented
     Built
     Nourishment
     Febrile/ afebrile
     Pallor (Anemic/not anemic)
     Icteric/not
     Clubbing
     Cyanosis
     Pedal oedema
     Significant lymphadenopathy
     Conjunctival congestion
    Vital signs:
     Pulse rate:
     BP: ………….. mm Hg …………..limbs……………posture
     Respiratory rate, rhythm, type
     Temperature

    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 Movement with respiration
    o Scars, discharging sinuses(TB)
    o intercostal fullness, indrawing, crowding of ribs,
    o Tracheal position with Trail’s sign
    o Apical impulse
    o Drooping of shoulders
    o Harrison’s sulcus
    o Kyphoscoliosis
    o Dilated veins over chest,
    o 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, Inter Costal tenderness
    o Vocal fremitus
    o Lymph nodes - Cervical, Supra axillary, 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 afer 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 Succession splash
    o Coin test

    Other systems:
    CVS :
    Abdomen:
    CNS:

    Diagnosis:

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