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RESPIRATORY SYSTEM
NAME: AGE: SEX: ADDRESS: OCCUPATION

CHIEF COMPLAINTS: IN PATIETS OWN WORDS, IN CHRONOLOGICAL ORDER HISTORY OF PRESENT ILLNESS: COUGH WITH EXPECTORATION HEMOPTYSIS BREATHLESSNESS FEVER, EVENING RISE OF TEMPERATURE CHESTPAIN WHEEZE SYNCOPE SYMPTOMS OF UPPER RESPIRATORY ILLNESS PEDAL EDEMA & PUFFINESS OF FACE BONE & JOINT PAIN & MUSCLE WEAKNESS HEAD ACHE, ALTERED MENTAL STATUS PERSONALITY CHANGES & OTHER NEUROLOGICAL SYMPTOMS SYMPTOMS OF OTHER SYSTEMIC ILLNESS -ONSET
-DURATION -PROGRESSION -AGGRAVATING FACTORS -RELIEVING FACTORS -VARIATIONS -OTHERS

PAST HISTORY: H/O SIMILAR COMPLAINTS IN THE PAST TB / ASTHMA / DM / HTN RECURRENT ATTACKS OF PLEURISY & PNEUMONIA PREVIOUS CHEST TRAUMA & SURGERY H/O OF ALTERED CONCIOUSNESS & VOMITING PREVIOUS H/O OF ALLERGY H/O OF SINUSITIS RISK FACTORS FOR EMBOLISM

FAMILY HISTORY: o o o H/O SIMILAR COMPLAINTS IN THE PAST TB / ASTHMA / DM / HTN BRONCHIECTASIS

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2 PERSONAL HISTORY: LOSS OF WEIGHT & APPETITE DIET SLEEP SMOKING ALCOHOLISM HIGH RISK BEHAVIOUR BLADDER, BOWEL

OCCUPATIONAL HISTORY: o EXPOSURE TO ORGANIC / INORGANIC DUST

TREATMENT HISTORY: PRESENT MEDICATION ATT INHALERS DRUG ALLERGY

GENERAL EXAMINATION

CONCIOUS , COHERENT BUILT & NOURISHMENT PALLOR ICTERUS CYANOSIS CLUBBING PEDAL EDEMA LYMPHADENOPATHY STIGMA OF TB

VITAL SIGNS: TEMPERATURE PULSE BP RESPIRATORY RATE, MECHANICS OF RESPIRATION JVP

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EXAMINATION OF THE UPPER RESPIRATORY TRACT

o o o o o

NOSTRILS NASAL SEPTUM SINUS TENDERNESS PHARYNX TONSIL

EXAMINATION OF THE LOWER RESPIRATORY TRACT

INSPECTION:
SPINE SHAPE OF CHEST SYMMETRY OF CHEST (BULGINGS/FULLNESS/FLATTENING /CROWDING OF RIBS/ DROOPING OF SHOULDER) POSITION OF TRACHEA, APICAL IMPULSE MOVEMENTS OF CHESTWALL MECHANICS OF RESPIRATION VISIBLE SCARS, SINUSES, DILATED VIENS, PULSATIONS SUPRACLAVICULAR FOSSA INFERIOR ANGLE OF SCAPULA / SPINO SCAPULAR DISTANCE

PALPATION:
o o o o o o POSITION OF TRACHEA & APICAL IMPULSE LOCAL RISE OF TEMPERATURE RESPIRATORY MOVEMNETS MEASUREMENTS: (EXPANSION A-P, TRANSVERSE, RT-LT HEMITHORAX) VOCAL FREMITUS INTERCOSTAL & RIB TENDERNESS

PERCUSSION:
NORMAL LUNG RESONANCE , ABNORMAL PERCUSSION NOTES LIVER DULLNESS CARDIAC DULLNESS SHIFTING DULLNESS TIDAL PERCUSSION TRAUBES AREA PERCUSSION KRONIGS ISTHMUS SUCCUTION SPLASH / COIN TEST

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AUSCULTATION:
BREATH SOUNDS: INTENSITY - CHARACTER TYPE OF BREATHING & ALTERATION OF INSPIRATION & EXPIRATION ADDED SOUNDS: WHEEZE, CRACKLES, PlEURAL RUB VOCAL RESONANCE BRONCHOPHONY, AGOPHONY WHISPERING PECTORILOKY

EXAMINATION OF OTHER SYSTEMS o o o o

CVS CNS GIT OTHER RELATED SYSTEMS

PROVISIONAL DIAGNOSIS: INVESTIGATIOPNS: TREATMENT: CBP , ESR SPUTUM GRAM STAINING, CULTURE & SENSITIVITY BLODD CULTURE CHEST X-RAY CT CHEST PLEURAL FLUID ANALYSIS OTHER RELATED INVESTGATIONS

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