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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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