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EXAMINATION OF RESPIRATORY SYSTEM

Case sheet format

Gender :
Address : Occupation :

Chief complaints and Duration: (To be described in patients own words)

To be in chronological order

The following symptoms need to be given importance:

✦ Cough ✦ Chest Pain

✦ Sputum ✦ Hemoptysis

✦ Breathlessness ✦ Wheeze
✦ Loss of appetite and weight ✦ Fever

HISTORY OF PRESENT ILLNESS

Each and every complaint needs to be analyzed systematically (Symptom Analysis)

Cough:
Duration, Onset, Diurnal variation, Aggravating & Relieving Factors, Which time of the day the
cough is present, Character ( like bovine cough, Brassy cough etc), Associated symptoms (like
syncope, chest pain, dyspnoea etc.), Postural variation, whether dry cough or productive cough.
If productive cough, Describe the sputum: Duration, Consistency, Quantity (3 layered sputm if
quantity is more), colour, Postural variation, Blood present or absent, Odour and any other …

BREATHTHLESSNESS:
First confirm it is actually breathlessness; Duration; Onset ...how it started (sudden, gradual) and
Progress (same grade throughout or improving or worsening); then Grade it. Grade 1 to 4 as per NYHA
criteria; Aggravating Factors; Relieving factors; Orthopnea and Paroxysmal Nocturnal Dyspnoea;
Platypnea and Trepopnea; associated symptoms like bluish discolouration of the lips, finger tips etc.

Chest Pain:

Duration; Onset; Site; Type or Character (Pricking, Burning, Dull aching etc); Continuous or Intermittent;
Aggravating Factors; Relieving factors; Radiation of the pain; Associated features like sweating,
palpitation and any other points.

Wheeze:
How Started, Progress, Treatment taken & Response to Treatment, Present Condition &
Medications
Other Symptoms:
1. H/o. Fever / Loss of Weight / Loss of Appetite.
2. H/o. Dysphagia / Hoarseness of Voice / Puffiness of Face / Fullness of Neck
3. H/o. swelling of feet / Oliguira / Distention of Abdomen

HISTORY OF PAST ILLNESS

o Similar illness in the past

o Aspiration / Unconsciousness / GA / Tooth Extraction /
Dentures/Anesthesia/Coma
o H/o. Exanthematous illness,
o Near Drowning, Epilepsy, Foreign Body aspiration
o H/o. Symptoms related to other systems / Joint Pain / Skin Rashes, etc.,
o H/o Tuberculosis, treatment taken ( including the name of drugs), Duration of
treatment, completed or not, relapse etc.
o H/o. Asthma / Allergy / Sinusitis

✦ Diabetes Mellitus ✦ H/o. Blood Transfusion

✦ Hypertension

✦ Bronchial Asthma
PERSONAL HISTORY:

Diet: Vegetarian/ Non vegetarian (actually we need to ask their full diet, because the term Vegetarian/
Non vegetarian may not give us the correct details.

Exercise:

Lifestyle:

Smoking: How long; How many cigarettes or beedies or other types;

Alcohol: How much and how long?; type of alcoholic beverage? etc

Chewing : TOBACCO /PAWN/Betel Nut etc

Drugs: Oral or Intravenous, Type of drugs?

Sensitive and Sexual History:

History of exposure to sexually Transmitted Diseases; Extra Marital relationships, Intra Venous drug use
etc.

Family History:

o About the patient, his parents, his children if married

o Married or not:

o If married, Time since marriage?

o Consanguinity; Number of children; other relevant details.

If possible, draw the Family Tree

Family history of Hypertension, Diabetes Mellitus, Tuberculosis, Dyslipidemia, Congenital illnesses etc.

Menstrual/Obstetrical/Gynaecological History: in case of females.

o Menarche; if yes, at what age it is attained?

o Menstrual Cycles - REGULAR/IRREGULAR, FLOW, FREQUENCY, ASSOCIATED PAINS

o Menopause: At what age it is attained?

o Post Menopausal symptoms

After the full history, try to analyse the symptoms and think about the various diseases that
can occur in this particular patient. Try to write down the differential diagnosis at this stage
itself.
Step 1: What are the systems involved?

Step 2: Try to classify the diseases......Congenital, Traumatic, Infective(viral, bacterial, parasitic, fungal
etc) Inflammatory, Degenerative, malignant, others....and try to name the disease...

1.

2.

3.

EXAMINATION:

General Examination:

(Exam the patient from Head to Foot and look for abnormalities.)

The first point is whether the patient is comfortable at rest or not?

Then systematically examine......and look for signs.

Build/Nourishment/orientation/cooperation

Height/Weight/BMI

Facies

Scalp

Eyes....Conjunctiva, Cornea, pupils and others for pallor of Conjunctiva, Jaundice, Arcus Senilis, KF Ring,
and others.

Ear and Nose

Oral cavity (Mouth)...lips, inner side of cheeks, angle of the mouth, tongue, soft and hard palate, uvula
and others

Neck...Thyroid, lymph nodes and other swellings and sinuses

Upper and lower limbs and trunk

But mainly look for the following signs....

o Anemia, Jaundice, Clubbing, Pitting pedal oedema, rashes over the skin etc.

o Nervous system: look for neuro cutaneous markers

o Abdomen: Look for signs of liver cell dysfunction

 o CVS: Markers of congenital heart disease

Vital Signs:

Pulse: Rate, Rhythm, Volume, Character, Condition of the vessel wall, all peripheral Pulses felt or not,
both radials equally felt or not, Radio Femoral Delay

Blood Pressure: Lying and Standing; both upper limbs and at least in one of the lower limbs.

Respiratory Rate and Rhythm:

Temperature:

Examination of Respiratory System:

Upper Respiratory Tract
Look for sinus tenderness ( by applying pressure over the maxillary and frontal sinuses)
Nasal septal deviation, Nasal polyps
Oral cavity: hard and soft palate, uvula, palatal arches, posterior pharyngeal wall, tonsils,
floor f the oral cavity. Angle of the mouth, dental..caries, poor oral hygiene
Examine the external canal of the ear
Lower Respiratory Tract
Inspection:
Methodology:
Frontal view, View from Behind, Aerial view and Supine view
Look for the following signs:
Thoracic Configuration (symmetry and shape)
Drooping of the shoulders, supra and infra clavicular hollowing/fullness,
Flattening of the chest, Barrel shaped chest
Sternum:
Pigeon chest (pectus Carinatum) and Pectus excavatum
Ricketty rosary
Intercostal spaces ( widening/narrowing) and indrawing, Retraction
Spine:
Kyphosis and Scoliosis, Gibbus deformity
Tracheal position:
 Movements of the chest wall:
Whether equal on both sides, Look for Harrisons sulcus, Accesory muscles of respiration
functioning or not, Costal paradox, abdominal paradox,
Other signs:
✦ Tracheal Tugging ✦ Stridor

✦ Skin Lesions ✦ Scars & Sinuses

✦ Pulsation & Pulsatile Buldge ✦ Engorged Veins Over Chest Wall

✦ Localized Swelling ✦ Chest Wall Edema

✦ Empyema Necessitans

Palpation:
o Confirm the tracheal position
o Movements of the chest wall (equal on both sides or not, upper lobes, lower lobes)
o Measurements
o Anteroposterior & Transverse Diameter
o Spinoscapular distance
o Intercostal Spaces (Tenderness)
o Tender Rib (Fracture rib, Osteomyelitis, Secondaries, etc.)
o Sternal Tenderness (Leukemia)
o Vertebral Tenderness (Pott’s Spine, Secondaries, etc.)
o Dilated Veins Over Chest Wall
o Direction of Flow
o Vocal Fremitus
o Tactile Fremitus (Palpable Rales)

Percussion:
Note: Follow the three cardinal rules of percussion
The chest needs to be divided into various areas (follow the steps given below)
RIGHT LEFT
 ✦ Kronig’s isthmus ✦ Kronig’s Isthmus

✦ Clavicular Percussion ✦ Clavicular Percussion

✦ Intercostal Percussion ✦ Intercostal Percussion

✦ Infraclavicular ✦ Infraclavicular

✦ Mammary ✦ Mammary

✦ Axillary ✦ Axillary

✦ Infra Axillary ✦ Infra Axillary

✦ Supra, Inter and Infra ✦ Supra, Inter and Infra

Scapular Scapular

In appropriate cases the following signs need to be looked for:

Shifting dullness
Straight line dullness
Ellis “S” Shaped dullness
Tidel percussion
Traube’s Space

Auscultation:
o Breath Sounds
o Intensity (compare both sides)
o Character ( Vesicular, Broncho vesicular or Bronchial)
If bronchial,
- Tubular, Cavernous, or Amphoric
o Adventitious Sounds
o Crepitations – Fine / Coarse
▪ Inspiratory
▪ Rhonchi - High Pitch / Low Pitch
 ▪ Monophonic / Polyphonic
o Vocal Resonance
o Whispering Pectoriloquy
o Bronchophony
o Egophony
o Succussion Splash
o Coin Sound Test
✦ Scratch Test
✦ Click Sound
✦ “D’ Espine Sign
✦ Post Tussive Suction
✦ Post Tussive Rales
✦ Hamman’s Sign
✦ Ewart’s Sign
Examination of other systems:
CVS:

Abdomen:

CNS:

Summary of findings (Follow SOAP – Subjective, Objective, Assessment and Plan-):

Differential Diagnosis:
Investigations

Final Diagnosis:
Note: The following components need to be included in the diagnosis
✦ Pathological {General, Special}
✦ Anatomical
✦ Etiological Diagnosis
Treatment
Complications

IMPORTANT CASES
✦ T.B. Fibrosis ✦ Pneumothorax

✦ T.B. Cavity ✦ Hydropneumothorax

✦ Penumonic Consolidation ✦ Cystic Fibrosis

✦ Pleural Effusion ✦ Emphysema & COPD

✦ Fibrothorax ✦ Collapse

✦ Hydrothorax – Bilateral ✦ Bronchopleural Fistula

✦ Empyema ✦ Pott’s Spine

✦ Lung Abscess ✦ Bronchogenic Carcinoma with SVC

✦ Bronchiectasis Obstruction