Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Respiratory System Handwritten Notes
I.
Introduc on
Name:
Age:
Sex:
Handedness:
Resident of:
Educa on: Occupa on: Religion: Informant: Reliability:
II.
Chief Complaints (in chronological order)
I I.
HOPI
1) Cough- Onset, Dry/Wet, Day/Night/ Postural/seasonal varia on, associated
with, aggravated by / relieved by, present status
2) Expectora on- Color, Consistency, Quan ty, Smel , Diurnal/ Postural varia on,
More in the early morning, Aggravated by / Relieved by, Present status
3) Hemoptysis- Color, Quan ty, Frequency, Postural varia on, Associated with,
Last episode, Postural symptoms, Aggravated by / Relieved by, Present status
4) Dyspnoea- Onset, Progression (describe wrt ac vi es), Associated with,
Aggravated by / Relieved by, Present status, MMRC grading (0-4), PND,
Orthopnoea
5) Wheeze- Dura on , Periodicity, Seasonal/ Diurnal varia on, Associated al ergic
features like al ergic rhini s, ur caria, recurrent sneezing, Aggravated by /
Relieved by, Present status
6) Chest pain-( OLD CAARTS) Onset, Loca on, Dura on, Character, Associated
features, Aggrava ng and Relieving factors, Radia on, Time, Severity
7) Fever- Grade, Max Temp, Type, Associated with chil s& rigors, Diurnal
varia on, Evening rise of temp., night sweats, relieved by, present status
8) Anorexia
9) Weight
loss-
Quan fied/Unquan fied,
lnten onal
/Uninten onal,
Significant/insignificant
10) Hoarseness of voice
11) Ptosis
12) Recurrent respiratory infec on
13) History sugges ve of Col agen Vascular Disease-Joint pain/rash/oral
ulcers/seizures/excessive hairfal
14) Palpita on /Easy fa guability
15) Bladder / Bowel symptoms
16) Swel ing of face/ edema
17) CNS symptoms-LOC/Head ache/weakness/vomi ng
IV.
Past History
DM/ HTN / TB/ Bronchial asthma/IHD
Childhood infec on
Jaundice/ Blood Txn
Al ergies/ FB inhala on
Trauma/ Surgeries/ similar il ness in the past
V.
Personal History
Smoking - pack years/smoking index/ Chula smoking
Alcohol / Tobacco
Veg / Non veg
Marital status/ Children/Menstrual history in detail
High risk behavior/Bladder/Bowel/Sleep
Immuniza on history
Socio-economic status/ over crowding
VI. Family history
TB/ Similar il ness in the family
VI . Treatment history
VI I. Summary at the end of the history
IX. Impression/ DD
General physical examina on
Conscious/oriented/comfortable
Ht- Weight- BMI- Temp-
Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F delay, Pulse
deficit, Vessel wal , Caro d bruit)
BP-
mmHg,
Respira on - Rate, Rhythm, Type (Abdomino-Thoracic /
Thoraco-Abdominal)
SpO2- BCG scar
P/J/Cy/Cl/LNE/PE/JVP/rash/facial plethora/neck veins/puffiness of face/ Pemberten
sign /Lt supra clavicular LN /Voice/asterixis
Signs of Malnutri on- Temporal / Buccal fat was ng, Hol owness of supraclavicular ?
infraclavicular fossae, Emaciated look
Nico ne stain- lips, Nail, teeth, gums, Vitamin deficiencies
Spine ? Kyphosis / Scoliosis /Gibbus, Skul
Peripheral signs of TB / Sarcoid / HIV
Marfanoid features, Thyroid, Testes, Low hair line, Horners Features, Congenital
anomalies
Systemic Examina on
Respiratory System:
Upper Respiratory Tract
Ear, Nose ( polyps, postnasal drip, DNS )
Throat ( tonsils, oral hygiene, nico ne stain )
Inspec on
Chest symmetry, Pectus excavatum/ Carinatum
Shape of chest
Respiratory movements - equal / decreased
Tracheal posi on / Trail sign
Signs of volume loss ? shoulder droop/was ng ( supra/infra clavicular)/Nipple posi on/
Spino scapular distance/ Rib crowding/ Intercostal spaces
Intercostal space indrawing / Hoover's sign/Respiratory paradox/ Respiratory alternans
Accessary muscles of respira on
Apical impulse
Dilated veins/Scars/Sinuses/Visible pulsa ons/Skin
Palpa on
Inspiratory findings confirmed
Tracheal posi on
Apical impulse
Rib crowding
Chest wal tenderness/ Crepitus / SC emphysema/ Nodules / LNE
Harrison's sulcus / Hoover's sign
Measurements
Spino
Antero-Po
Chest
Expansion
Hemithorax Hemithorax
Transverse
Circumferance
expansion
Scapular
sterior
Distance
Diameter
Diameter
Right
Le
Supra
Infra
Infra
Supra
Inter
Infra
Mammary Axil ary
Clavicular clavicular
Axil ary Scapular Scapular Scapular
Respiratory
Rt
Movement
Lt
Rt
Percussio Lt
n
Kronig's
Rt
Isthmus
Lt
Percussion
Rt
over
Lt
clavicle
Percussion over Traube Space
Liver Dul ness, Tidal Percussion
Ausculta on
Supra
Infra
Infra
Supra
Inter
Infra
Mammary Axil ary
Clavicular clavicular
Axil ary Scapular Scapular Scapular
Rt
Air Entry
Lt
Rt
VF, VR
Lt
Rt
VBS
Lt
Rt
Bronchial
Breathing
Lt
Wheeze/
Rt
Rhonchi
Lt
Rt
Crackles
Lt
Whispering
Pectroloquy
Aegophony
Pleural Rub
Cardio-Vascular System
Apical Impulse
Precardial buldge, Parasternal heave
Palpable sounds, Thril
S1,S2,S3,S4
Murmurs
Abdomen
Symmetry/Distension
Al quadrants moves with respira on
So , Tenderness, Liver, Spleen, Any mass, Bowel sounds, Hernial orifices
Central Nervous System
Consciousness,Orienta on
FND, Horner's Syndrome, Planters
Summary a er Examina on
Diagnosis/DD
Inves ga on
Treatment
This post was last modified on 11 August 2021