LRTI Case History Presentation Format

1. Identification Data

• Name:
• Age/Sex:
• Address:
• Date and time of admission:
• Informant and reliability:
• Hospital/OPD number:

2. Chief Complaints

• Cough for ___ days
• Fever for ___ days
• Expectoration for ___ days
• Breathlessness for ___ days
• Chest pain/wheeze for ___ days

3. History of Present Illness

• Onset: sudden/gradual
• Duration and progression: improving/worsening/static
• Type: dry or productive
• Sputum: amount, color, odor, blood-stained, rusty, purulent
• Diurnal variation: worse at night/morning
• Aggravating/relieving factors
• Associated symptoms:
  • Fever: intermittent/continuous, chills, rigors, sweating
  • Breathlessness: onset, grade by mMRC, at rest/on exertion, orthopnea/PND
  • Pleuritic chest pain
  • Wheeze
  • Hemoptysis
  • Sore throat/rhinorrhea
  • Myalgia, headache, vomiting, diarrhea
  • Loss of appetite, weight loss, night sweats

4. Negative History

• No history of tuberculosis contact, chronic cough, significant weight loss, or night sweats
• No recurrent similar episodes
• No aspiration episode, choking, or altered sensorium
• No recent hospital admission or antibiotic use
• No known COVID-19/influenza exposure
• No edema, orthopnea, or paroxysmal nocturnal dyspnea
• No occupational dust/fume exposure
• No immunosuppressive therapy

5. Past History

• Previous respiratory infections, pneumonia, tuberculosis, asthma, COPD, bronchiectasis
• Diabetes, hypertension, heart disease, chronic kidney/liver disease
• HIV/immunosuppression or malignancy
• Previous hospitalization, ICU admission, intubation
• Drug history, especially recent antibiotics and steroids
• Allergy history
• Vaccination history: influenza, pneumococcal, COVID-19

6. Personal History

• Appetite, sleep, bowel and bladder habits
• Smoking history: pack-years
• Alcohol or substance use
• Occupational history
• Exposure to biomass fuel, pollution, sick contacts, pets/birds
• Travel history, if relevant

7. Family History

• Similar illness/contact with tuberculosis
• Asthma, atopy, chronic lung disease
• Hereditary illness, if relevant

Examination

General Physical Examination

• General condition: conscious, cooperative, oriented
• Build and nourishment
• Temperature
• Pulse, blood pressure, respiratory rate
• SpO₂ on room air and oxygen requirement
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
• Hydration status

Respiratory System Examination

• Shape and symmetry of chest
• Respiratory rate, rhythm, depth
• Use of accessory muscles
• Intercostal/suprasternal retractions
• Tracheal position
• Chest movement and expansion

• Tracheal position
• Chest expansion
• Tactile vocal fremitus
• Tenderness

• Resonant/dull/stony dull/hyper-resonant note

• Air entry: equal or reduced
• Breath sounds: vesicular/bronchial
• Added sounds: crackles/crepitations, wheeze, rhonchi
• Vocal resonance: increased/decreased
• Pleural rub, if present

Other Systemic Examination

• Cardiovascular system
• Abdomen
• CNS examination

Clinical Summary Example

A ___-year-old ___ presented with acute onset fever, productive cough with ___ sputum, and progressive breathlessness for ___ days. Examination showed fever, tachypnea, SpO₂ ___% on room air, and ___ findings over the ___ lung zone, suggestive of a lower respiratory tract infection, likely community-acquired pneumonia.

Provisional Diagnosis

• Acute lower respiratory tract infection
• Likely community-acquired pneumonia involving ___ lobe, with/without:
  • Hypoxemia
  • Sepsis
  • Pleural effusion
  • Acute exacerbation of COPD/asthma

Differential Diagnoses

1. Acute bronchitis
2. Community-acquired pneumonia
3. Viral pneumonia, including influenza/COVID-19 where epidemiologically relevant
4. Acute exacerbation of COPD or asthma with infection
5. Pulmonary tuberculosis
6. Bronchiectasis with infective exacerbation
7. Acute heart failure/pulmonary edema
8. Pulmonary embolism, if pleuritic pain, hemoptysis, tachycardia, or risk factors are present

Suggested Investigations

• CBC with differential count
• CRP, and procalcitonin only if it will change management
• Pulse oximetry and arterial blood gas if hypoxemic or severely ill
• Chest X-ray PA view
• Sputum Gram stain, culture and sensitivity if productive cough/severe illness
• Blood cultures before antibiotics in severe pneumonia
• Viral testing as clinically indicated
• Renal function tests, liver function tests, blood glucose, electrolytes
• ECG if elderly, severe illness, chest pain, or cardiac disease
• TB testing if symptoms/risk factors suggest tuberculosis

Red Flags to State During Presentation

• SpO₂ < 94% on room air, or lower than the patient's baseline
• Respiratory distress, cyanosis, inability to speak full sentences
• Hypotension, altered sensorium, confusion
• Persistent high fever/rigors or suspected sepsis
• Hemoptysis
• Severe pleuritic chest pain
• Frailty, pregnancy, immunosuppression, advanced age, or major cardiopulmonary comorbidity