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Clinical Case Presentation Proforma for Respiratory System

Method · July 2019

DOI: 10.13140/RG.2.2.25781.22243

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Jebin Abraham
Government Medical College, Patiala
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 Clinical Case Presentation Proforma for
Respiratory System
Identification
Name, Age, Sex, Address, Occupation

Presenting complaints/Chief complaints

Cough, Expectoration, Haemoptysis, Breathlessness, Chest pain, Wheezing,
Fever, Loss of appetite, Loss of weight

History of Present Illness

1. Cough : Duration, Onset, Progress, Episodes, Aggravating factors, Relieving
factors, Variations {diurnal/seasonal/postural}

2. Expectoration : Duration, Onset, Progress, Episodes, Quantity, Colour,

Consistency, Smell, Aggravating factors, Relieving factors, Variations
{diurnal/seasonal/postural}

3. Haemoptysis: Duration, Onset, Progress, Episodes, Fresh/altered, Amount,

Aggravating factors, Relieving factors

4. Breathlessness: Duration, Onset, Progress {grade}, Episodes, Lasting,

Orthopnea, PND, Aggravating factors, Relieving factors, Variations {diurnal/
seasonal/ postural}, Asso wheeze

5. Chest pain: Duration, Onset, Progress, Episodes, Lasting, Site, Type,

Radiation, Aggravating factors, Relieving factors

6.Wheeze: Duration, Onset, Progress, Episodes, Lasting, Aggravating factors,

Relieving factors, Variations {diurnal/seasonal}, Asso skin rashes, Allergy{dust,
food etc}

7. Fever : Duration, Onset, Progress, Episodes, Grade, {Documented or not},

Asso chills & rigor, Night sweats, Aggravating factors, Relieving factors,
Variations

8. LOA & LOW: Duration, Onset, Progress, Amount { if documented}

[Negative history should be specified wherever necessary to rule-out any

particular illness/involvement of any other systems]
Past History
1. H/o TB/ATT: how many times taken, Govt/pvt, important dates, CXR
finding, Sputum +ve/-ve, F/u sputum, regimen, duration of treatment,
tolerance issues, completed/cured/defaulted{why?}, CBNAAT/LPA/LC
reports etc
2. Immunisation h/o
3. Recurrent childhood chest infections/Measles, Pertussis/Chest injury
4. DM, HTN, Br. Asthma, Heart disease, Jaundice, HIV, Seizures/LOC /
General anesthesia{ or any other significant illness}
5. H/o drug intake/treatment: Immunosuppressants/Chemo/Radiation
6. H/o any surgery
Family History
1. TB : All necessary details as mentioned above
2. Respiratory diseases- Asthma, COPD, others
3. DM,HTN, Ca
Personal History
Occupation: Present & past, industrial dust, pets
Diet, Sleep, Appetite, Bowel & bladder habits
Addictions:
Smoking { duration, type of product, amount [pack years/smoking index], h/o
passive smoking}
Alcoholism { duration, amount, type}
Others, if any
H/o recent travelling

General physical examination

Patient is dyspneic at rest/Sitting comfortably on bed/Lying on left lateral
position
Conscious, cooperative and well oriented in time, place and person
Well/Moderately/Poorly built and nourished
-Height:
-Weight:
- BMI:
Pallor-
Icterus-
Cyanosis-
Clubbing(with grade)-
Lymphadenopathy-
Edema-
Pulse- {eg. 90 beats per minute, regular in rhythm, character normal, high
volume, no RF delay, no RR delay, condition of vessel wall normal, all peripheral
pulses felt equally on both sides}
BP- {eg. BP is 120/80mmHg in right arm, in supine position}
Resp Rate-{eg. 18/minute, regular, abdominothoracic}
JVP- {not raised/raised}
Temperature- {eg. 101degF/afebrile}
sPO2-
Skin, hair and nail
Thyroid enlargement
ICD tube in situ at Left infra-axillary area, IV cannula in situ at left forearm

*{GPE should include a head to foot examination. Any significant abnormal

findings should be included in GPE}

Examination of Respiratory System

A)Upper Respiratory Tract
- [WNL] or
- Sinus tenderness
- Flaring of nasal alae
- DNS
- Nasal polyps
- Oral cavity→ Oral hygiene
Loss of tooth/tooth caries
Halitosis
Enlarged tonsils

B) Lower respiratory tract and Chest

Inspection
Shape of chest {N/Barrel/Flat/excavatum/carinatum...}
Trachea- Appears to be central [Trail sign present/absent]
Accessory muscles of respiration- {being used/not}
Intercostal indrawing
Apex beat {visible/not}
Any other precordial/epigastric pulsations
Symmetry of Chest
- B/l symmetrical {Depresed/bulged}
- Supraclavicular fossa {fullness/ hollowing}
- Suprascapular wasting
 - Infraclavicular flattening
- Drooping of shoulder
- Crowding of ribs[if visible]
Kyphoscoliosis {eg, scoliosis present with concavity to left}
Subcostal angle- appers normal[70 deg]
Skin over chest-{N/dilated veins/scars/sinuses}
Movements- Appears to be equal [diminished in
supraclavicular/infraclavicular/mammary/suprascapular/infrascap
ular area]
Palpation
Local rise of temperature
Tenderness
All inspectory findings confirmed
Trachea-
Apex beat- {eg, Palpable at left 5th ICS, 1.25cm medial to mid-
clavicular line, character-N/tapping/heaving}
Chest Movements-
Tactile vocal fremitus-{N/increased/decreased}
Palpable rub/rhonchi/creps
Crowding of ribs-
Measurements-
- AP diameter:
- Transv diameter:
- AP:Transv ratio:
- Chest circumference: Expansion:
- Rt hemithorax: Expansion:
- Lt hemithorax: Expansion:
- Spino-acromial:
- Spino-scapular:

Percussion
{eg, B/l normal resonant notes in all lung fields}
[Hyper-resonant/impaired/dull/stony dull ]
Liver dullness- {eg, upper border of liver- right 5th ICS, Liver span-...cm }
Cardiac dullness- WNL/could not be percussed out
[ Right border corresponds to that of sternum
Left border corresponds to apex beat
Left 2nd ICS esonant/dull]
Special tests: Shifting dullness/tidal percussion/Kronig’s -
isthmus/Traube’s space
 Auscultaion
Character & intensity of BS {eg, B/l normal vesicular breath sounds with
equal intensity}
[bronchial/b-v/cavernous/amphoric]
Added sounds- Rhonchi[U/l or b/l, mono/polyphonic]
- Crepitations[type,area]
Vocal resonance- [N/incr/decr]
Specific tests: Coin test, succession splash, post tussive -
crepitation/suction etc

Examination of Other Systems

CNS- Higher mental functions –N, Sensory & motor functions intact
CVS- S1&S2 heard normally, No murmer
GIT- Abdomen soft, No organomegaly
Musculoskeletal systm- Skull & Spine normal, No bony deformities

Provisional Diagnosis
1. Side [R/L]
2. Lobe [ Upper/lower]
3. Pathology {eg, bronchiectasis}
4. Etiology {eg, post-Tb/smoking}
5. Not in respiratory failure
6. Not in corpulmonale

*Special findings/tests [eg, Aegophony, whispering pectoriloqui, coin

percussion, tidal percussion succession splash, pemberton’s sign..... etc ] should
be included in the proforma depending on the case and whenever it appears
relevant according to the clinician]

For Suggestions:
Dr. Jebin Abraham, MD
Faculty of Pulmonary Medicine
Government Medical College, Patiala
Email: drjebin@allergist.com

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