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RESPIRATORY SYSTEM (RS) CASE SHEET

Detailed History Taking for Medicine Postings

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SECTION A: PATIENT IDENTIFICATION

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SECTION B: CHIEF COMPLAINTS

1. _________________________________________ since _________
2. _________________________________________ since _________
3. _________________________________________ since _________
4. _________________________________________ since _________

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SECTION C: HISTORY OF PRESENTING ILLNESS (HOPI)

Detailed elaboration of each chief complaint using SOCRATES / LIQOR AAA framework.

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1. COUGH

• Onset: Sudden / Gradual
• Duration: Acute (<3 weeks) / Subacute (3–8 weeks) / Chronic (>8 weeks)
• Type: Dry / Productive / Brassy / Barking / Bovine / Whooping / Nocturnal
• Timing: Continuous / Paroxysmal / Morning / Nocturnal / Postprandial
• Progression: Static / Increasing / Decreasing
• Precipitating factors: Cold air / Dust / Smoke / Exercise / Lying down / ACE inhibitors
• Relieving factors: Sitting up / Inhalers / Medications
• Associated features: Sputum / Blood / Wheeze / Dyspnea / Fever / Voice change

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2. SPUTUM

• Onset & Duration:
• Amount: Scant / Moderate / Copious (measure in ml/day if possible)
• Color:
  • White/Mucoid → Bronchial asthma, viral URTI
  • Yellow/Green (mucopurulent) → Bacterial infection (COPD exacerbation, bronchiectasis)
  • Rust-colored → Pneumococcal pneumonia
  • "Red currant jelly" → Klebsiella pneumoniae
  • Black → Coal dust (anthracosis)
  • Pink frothy → Pulmonary edema
  • Prune juice → Amoebic lung abscess
  • Anchovy sauce → Amoebic empyema
• Consistency: Watery / Frothy / Thick / Tenacious / Gelatinous
• Smell: Odourless / Foul-smelling / Putrid (Anaerobic infections, bronchiectasis)
• Posture-related: 3-layer sputum on standing (bronchiectasis)
• Haemoptysis: Present / Absent (elaborate separately — see below)

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3. HAEMOPTYSIS (Coughing up blood)

• Onset: First episode / Recurrent
• Amount: Streaking / Frank blood / Massive (>200 ml/24 hr)
• Color: Bright red / Dark red / Mixed with sputum
• Mixed with: Sputum / Saliva / Food (differentiate from haematemesis)
• Associated: Chest pain / Dyspnea / Weight loss / Fever / Night sweats
• Differential diagnosis prompt:
  • Young patient + constitutional symptoms → TB
  • Middle-aged smoker → Carcinoma lung / COPD
  • Recurrent + purulent sputum → Bronchiectasis
  • Frothy pink → Pulmonary edema
  • Pleuritic pain + DVT risk → Pulmonary embolism
  • Mitral stenosis → Cardiac haemoptysis

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4. DYSPNEA (BREATHLESSNESS)

• Onset: Acute (minutes–hours) / Subacute (days) / Chronic (weeks–months)
• Duration & Progression: Static / Progressive / Episodic
• Grade (MRC Dyspnea Scale):

• NYHA Grading (if cardiac component suspected):
  • Class I–IV
• Type:
  • Exertional / Nocturnal / Postural (orthopnoea, platypnoea, trepopnoea)
  • Paroxysmal nocturnal dyspnoea (PND)
• Precipitating factors: Exercise / Lying down / Allergens / Smoke / Emotion
• Relieving factors: Rest / Sitting up / Oxygen / Inhalers / Diuretics
• Associated: Wheeze / Cough / Chest tightness / Cyanosis / Ankle swelling

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5. WHEEZE

• Onset & Duration:
• Type: Expiratory / Inspiratory / Biphasic
• Timing: Continuous / Episodic / Nocturnal
• Precipitants: Allergens / Cold / Exercise / Aspirin / Beta-blockers
• Relieving factors: Bronchodilators / Removing trigger
• Associated: Cough / Dyspnea / Chest tightness
• Atopic history: Allergic rhinitis / Eczema / Family history of atopy

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6. CHEST PAIN

• Site: Localized / Diffuse; Central / Lateral / Posterior
• Radiation: Shoulder / Arm / Neck / Back
• Onset: Sudden / Gradual
• Character: Pleuritic (sharp, stabbing, worse on inspiration/cough) / Dull aching / Burning / Tight / Squeezing
• Severity: VAS 1–10
• Duration: Constant / Intermittent
• Aggravating factors: Deep breathing / Coughing / Movement / Lying on affected side
• Relieving factors: Analgesics / Sitting forward / Leaning to affected side
• Associated: Fever / Haemoptysis / Dyspnea / Leg swelling
• Differential diagnosis prompt:
  • Pleuritic → Pleuritis, pneumonia, PE, pneumothorax
  • Central → Tracheobronchitis, mediastinitis, cardiac

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7. FEVER

• Onset: Acute / Insidious
• Duration:
• Pattern: Continuous / Remittent / Intermittent / Hectic / Pel-Ebstein (Hodgkin's)
• Severity: Low-grade / High-grade
• Associated: Chills & rigors / Night sweats (TB, lymphoma) / Diaphoresis
• Relieved by: Antipyretics (degree of relief)

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8. CONSTITUTIONAL SYMPTOMS

• Anorexia: Present / Absent — Duration
• Weight loss: Present / Absent — Amount (kg) over _____ months
  • Significant: >10% of body weight in 6 months
• Night sweats: Present / Absent (→ TB, lymphoma, HIV)
• Easy fatigability: Present / Absent
• Generalised weakness: Present / Absent

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SECTION D: PAST HISTORY

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SECTION E: DRUG & TREATMENT HISTORY

• Current medications (name, dose, duration, compliance):
  • ___________ mg ___ times/day × ___ months
• Previous medications: Steroids / Immunosuppressants / Chemotherapy
• Specific drug exposures:
  • ACE inhibitors → Chronic dry cough (up to 15% patients)
  • Beta-blockers → Bronchoconstriction in asthmatics
  • Amiodarone → Pulmonary fibrosis
  • Methotrexate → Interstitial lung disease
  • Bleomycin, busulfan → Pulmonary toxicity
  • NSAIDs/Aspirin → Aspirin-exacerbated respiratory disease
• Antitubercular therapy (ATT): If yes → duration, compliance, side effects
• OTC/Herbal remedies: _______________
• Allergies to drugs: Present / Absent — Specify drug and reaction type

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SECTION F: PERSONAL HISTORY

Smoking / Tobacco Use (Critical in RS)

• Smoking: Yes / No / Ex-smoker
• Type: Cigarettes / Bidi / Hookah / Pipe
• Pack-year history = (cigarettes/day ÷ 20) × years smoked
  • <10 pack-years → mild risk

  • 20 pack-years → significant COPD / lung cancer risk

• Age of initiation: ______
• Duration: _______ years
• If ex-smoker: Year stopped, duration smoked

Alcohol Use

• Present / Absent / Occasional / Regular
• Type: _______ Amount: _______ Duration: _______
• (Aspiration pneumonia risk; alcohol + TB link)

Diet

• Vegetarian / Non-vegetarian
• Adequacy: Adequate / Inadequate
• (Nutritional status relevant to TB, immunocompromise)

Bowel & Bladder Habits

• Bowel: Regular / Irregular / Constipated / Loose
• Bladder: Normal / Frequency / Nocturia / Dysuria

Sleep

• Normal / Disturbed / Orthopnoea / Paroxysmal nocturnal dyspnoea
• Snoring / Witnessed apnoeas → Screen for Obstructive Sleep Apnea (OSA)
  • Epworth Sleepiness Scale score if OSA suspected

Menstrual History (Females)

• LMP: _______ Cycle: Regular / Irregular
• Catamenial pneumothorax / haemoptysis if cyclical symptoms coincide with menstruation

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SECTION G: FAMILY HISTORY

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SECTION H: OCCUPATIONAL & ENVIRONMENTAL HISTORY (Crucial in Respiratory Medicine)

Occupational Exposures (Pneumoconioses, Occupational Asthma)

• Duration of exposure:
• Use of protective equipment (PPE): Yes / No
• Compensation sought: Yes / No

Home / Environmental Exposures

• Indoor air pollution: Cooking with biomass fuel (wood, dung, coal) — major COPD risk in women in developing countries
• Passive smoking: Yes / No — Duration
• Pets at home: Type _____ (cats/dogs/birds → allergens, hypersensitivity pneumonitis)
• Damp/Mold in home: Yes / No
• Recent travel: Domestic / International — (Endemic mycoses, TB, COVID)
• Area of residence: Urban / Rural / Industrial zone

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SECTION I: SOCIOECONOMIC & NUTRITIONAL HISTORY

• Family size: _______ members in _______ rooms
• Overcrowding (>2 persons/room): Yes / No (TB risk)
• Sanitation: Adequate / Inadequate
• Safe drinking water: Yes / No
• Socioeconomic class: (Kuppuswamy scale — based on education, occupation, income)
• Nutritional status: Well-nourished / Malnourished / Obese

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SECTION J: REVIEW OF SYSTEMS

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SECTION K: GENERAL PHYSICAL EXAMINATION

Vital Signs

General Survey

• Built & Nourishment: Well-built and nourished / Thin and wasted
• Consciousness: Alert / Drowsy / Confused (CO₂ narcosis in COPD)
• Pallor: Present / Absent (grade I–IV) (Anaemia → worsens dyspnea)
• Cyanosis: Central / Peripheral — Grade
  • Central cyanosis: bluish discoloration of tongue, lips → significant hypoxia (PaO₂ <60 mmHg; SaO₂ <85%)
• Clubbing: Present / Absent — Grade (Schamroth's sign)
  • Grade I: Increased fluctuation of nail bed
  • Grade II: Obliteration of Lovibond angle
  • Grade III: Parrot beak / drumstick appearance
  • Grade IV: Hypertrophic pulmonary osteoarthropathy (HPOA)
  • Causes in RS: Carcinoma lung, empyema, bronchiectasis, lung abscess, fibrosing alveolitis, mesothelioma
• Lymphadenopathy: Cervical / Supraclavicular / Axillary — Size, consistency, tenderness, fixity
  • Supraclavicular → TB, lymphoma, metastasis
• Edema: Pitting / Non-pitting — Grade, Distribution (Cor pulmonale → ankle edema)
• Jugular Venous Pressure (JVP): Normal / Elevated (Right heart failure, SVC obstruction)
• Jaundice: Present / Absent
• Cachectic appearance: Yes / No

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SECTION L: LOCAL EXAMINATION — RESPIRATORY SYSTEM

Inspection

• Normal (elliptical)
• Barrel chest: Increased AP diameter (AP:transverse = 1:1); COPD / emphysema
• Pectus excavatum (funnel chest): Inward sternum
• Pectus carinatum (pigeon chest): Outward sternum; childhood asthma
• Harrison's sulcus: Horizontal groove along lower ribs; childhood asthma/rickets
• Kyphoscoliosis: Affects lung volumes
• Asymmetry: Unilateral expansion / retraction

• Scars / Sinuses / Dilated veins (SVC obstruction)
• Intercostal retraction / Subcostal recession
• Tracheal position (visual) — deviated or not
• Precordial bulge / Rib prominence

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Palpation

• Midline / Deviated to right / Deviated to left
• Tracheal deviation toward lesion: Collapse, fibrosis
• Tracheal deviation away from lesion: Massive pleural effusion, tension pneumothorax

• Upper zone: Both sides simultaneously
• Middle zone
• Lower zone: Normal ≥3 cm bilaterally
• Reduced on side of: Effusion, collapse, fibrosis, consolidation, pneumothorax

• Tenderness (rib fracture, pleurisy)
• Subcutaneous emphysema (crepitus)
• Pleural rub (tactile)
• Lymph node palpation (axillary, supraclavicular)

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Percussion

• Anteriorly: Supraclavicular → infraclavicular → IC spaces (2nd, 3rd, 4th, 5th)
• Posteriorly: Supraspinatous → Interspinatous → Infraspinatous → Bases
• Laterally

• Liver dullness: Lower border (percuss down right side — normally 5th ICS, MCL)
• Cardiac dullness (left)
• Traube's space (left lower chest: normally tympanic — dullness → splenomegaly / left effusion)
• Shifting dullness → Pleural effusion (position change shifts dullness)
• Kronig's isthmus: Resonant band over apices (2–4 cm); absent in apical TB/fibrosis

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Auscultation

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SECTION M: SYSTEMIC EXAMINATION

Cardiovascular System

• Heart sounds, murmurs, S3/S4
• Signs of cor pulmonale: Elevated JVP, right ventricular heave, tricuspid regurgitation murmur, hepatomegaly, ankle oedema
• Signs of left heart failure (cause of secondary respiratory symptoms)

Abdomen

• Hepatomegaly (right heart failure, amyloid, malignancy)
• Splenomegaly (sarcoidosis, lymphoma)
• Ascites (cardiac failure, malignancy, TB peritonitis)
• Per-rectal examination if relevant

Central Nervous System

• Consciousness level, orientation
• Asterixis / flapping tremor (Type II respiratory failure / CO₂ narcosis)
• Signs of metastatic disease

Musculoskeletal

• Joint swelling/deformity (RA → ILD)
• HPOA: Periosteal new bone formation, wrist tenderness (Carcinoma lung)

Skin & Subcutaneous

• Erythema nodosum (TB, sarcoidosis)
• Lupus pernio (sarcoidosis)
• Subcutaneous nodules (RA, sarcoidosis)

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SECTION N: PROVISIONAL DIAGNOSIS

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2. ---

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SECTION O: INVESTIGATIONS PLANNED

Bedside / Point-of-Care

• SpO₂ monitoring (continuous)
• Peak Expiratory Flow Rate (PEFR)
• ABG (Arterial Blood Gas) — if SpO₂ <94% or respiratory distress

Hematological

• CBC with differential (eosinophilia → asthma/allergic; leukocytosis → infection; anaemia)
• ESR, CRP (infection, inflammation)
• Coagulation profile (if haemoptysis)

Biochemical

• RFT, LFT, Electrolytes (baseline before medications)
• LDH, ADA (pleural fluid studies)
• Serum procalcitonin (bacterial infection)
• Alpha-1 antitrypsin levels (if young COPD)

Microbiological

• Sputum: Gram stain, culture & sensitivity
• Sputum AFB smear × 3 (if TB suspected) + GeneXpert MTB/RIF
• Sputum cytology (malignancy screen)
• BAL if immunocompromised / atypical organisms

Immunological / Serological

• Mantoux test / IGRA (TB)
• ANA, anti-dsDNA, ANCA, anti-GBM (autoimmune ILD)
• IgE total + specific (atopy / allergic asthma)
• Serum ACE (sarcoidosis)

Pulmonary Function Tests (PFTs)

• Spirometry: FVC, FEV₁, FEV₁/FVC ratio
  • Obstructive: FEV₁/FVC <0.7 (COPD, asthma)
  • Restrictive: FVC reduced, FEV₁/FVC normal (ILD, pleural disease)
• DLCO (Diffusing Lung Capacity for CO): Reduced in ILD, emphysema
• Bronchodilator reversibility (for asthma diagnosis: >12% and 200 ml improvement in FEV₁)
• Bronchial provocation test (methacholine/histamine challenge)

Imaging

• Chest X-ray (PA view) — standard; lateral if needed
• HRCT chest — ILD, bronchiectasis, emphysema
• CT chest with contrast — malignancy, PE, mediastinal masses
• CT pulmonary angiography (CTPA) — gold standard for PE
• Ultrasound chest — pleural effusion (loculation), guided pleural tap
• PET-CT — staging of lung cancer
• V/Q scan — PE (if CTPA contraindicated)

Invasive Procedures

• Pleural fluid analysis (diagnostic/therapeutic tap): Biochemistry, cytology, culture, AFB, ADA
• Bronchoscopy ± BAL ± biopsy: For central lesions, hemoptysis
• FNAC / core biopsy: Peripheral lung / lymph node mass
• Video-assisted thoracoscopic surgery (VATS) biopsy: ILD, pleural disease
• Mediastinoscopy: Mediastinal lymphadenopathy

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SECTION P: SUMMARY

Example: "Mr. _______, a 55-year-old male, heavy smoker (40 pack-years), presenting with progressive exertional dyspnea (MRC grade 3), chronic productive cough with mucopurulent sputum, and bilateral wheeze for 5 years. On examination, there is barrel chest, bilateral polyphonic expiratory wheeze, and hyper-resonance on percussion. These findings are consistent with COPD (moderate–severe, GOLD stage III) with infective exacerbation."

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QUICK REFERENCE: RS SYMPTOM → DIAGNOSIS MATRIX

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