RESPIRATORY SYSTEM
HISTORY TAKING AND
EXAMINATION
� Patient Identification & Demographics
● Name
● Age
● Sex
● Occupation (e.g., exposure to dust, chemicals, asbestos)
● Address (may reveal environmental risk factors)
● Date and time of consultation
Chief Complaint (CC)
● The main symptom(s) in the patient’s own words.
● Duration of the symptom(s).
Examples: “I’ve had a cough for 2 weeks,” “Shortness of breath for a month.”
�History of Present Illness (HPI)
1. Symptom Analysis (OPQRST or SOCRATES)
1. Cough
- When did the cough start? (onset)
- Is it dry or productive?
- How often does it occur?
- Is it worse at any particular time of day or with activity?
- What triggers it? (cold air, dust, exercise, lying down)
- Is there any sputum? If yes: color, consistency, volume, odor?
- Any blood in the sputum?
- Any associated symptoms like fever, wheezing, weight loss?
2. Dyspnea (Shortness of Breath)
- When did the breathlessness start?
- Is it constant or intermittent?
- What brings it on? (e.g., exertion, lying flat, night time)
- Can you lie flat comfortably or do you use extra pillows?
- Do you wake up gasping for air at night? (PND)
- How far can you walk before becoming breathless?
- Any associated chest pain, wheeze, or cough?
3. Chest Pain
- Where is the pain located?
- When did it start and how did it begin?
- Can you describe the character (sharp, dull, stabbing)?
- Is it related to breathing, coughing, or movement?
- Does it radiate anywhere (shoulder, back, arm)?
- How long does it last and does anything relieve it?
- Any associated symptoms like breathlessness, fever, or hemoptysis?
4. Sputum Production
- Do you produce sputum regularly?
- How much sputum do you bring up daily?
- What is the color and consistency?
- Is there a foul smell?
- Is it worse at any particular time of day?
5. Hemoptysis (Coughing Up Blood)
- How much blood have you coughed up?
- Is it mixed with sputum or pure blood?
- How often does it happen?
- What color is the blood?
- Any history of TB, smoking, or lung disease?
- Any recent trauma or foreign body?
6. Wheezing
- When did the wheezing start?
- Is it constant or only at night/early morning?
- What triggers it (dust, cold, pets, smoke)?
- Is it associated with breathlessness or cough?
- Does it improve with inhalers or medications?
7. Fever with Respiratory Symptoms
- When did the fever start?
- Is it continuous or intermittent?
- Do you have chills or night sweats?
- Is the fever associated with cough, chest pain, or breathlessness?
- Any recent infections or contacts (e.g., TB, COVID)?
8. Noisy Breathing / Stridor
- Do you hear a high-pitched sound during breathing?
- When did it start?
- Is it worse when inhaling or exhaling?
- Any history of choking, foreign body, or trauma?
- Any drooling or difficulty swallowing?
9. Sleep-Related Symptoms (for OSA)
- Do you snore loudly?
- Has anyone noticed you stop breathing during sleep?
- Do you wake up gasping or choking?
- Are you excessively sleepy during the day?
- Do you wake up with headaches or dry mouth?
- Have you gained weight or have a large neck circumference?
�Past Medical History
● Previous respiratory illnesses:
○ Asthma
○ COPD
○ Tuberculosis
○ Bronchiectasis
○ Pulmonary embolism
○ Interstitial lung disease
● Hospitalizations for respiratory problems
● Prior intubation or ICU admission
● Any immunocompromised conditions (HIV, cancer)
�Drug History
● Current medications: e.g., inhalers, steroids, antibiotics
● Past treatment for TB or asthma
● Compliance
● Side effects
● OTC or herbal medications
● Allergies: Drugs, especially antibiotics
�Family History
● Asthma
● Tuberculosis
● Cystic fibrosis
● Lung cancer
● Genetic disorders (e.g., α1-antitrypsin deficiency)
�Social History
● Smoking history:
○ Current/former smoker
○ Pack-years = packs/day × years smoked
○ Type: Cigarettes, cigars, shisha, marijuana
● Alcohol use
● Occupational exposure:
○ Dust, asbestos, coal, silica, chemicals
● Travel history: TB endemic areas, COVID-19 exposure
● Living conditions: Crowding, poor ventilation
● Pets: Bird exposure (hypersensitivity pneumonitis)
�Systemic Review
(Relevant systems)
● Cardiovascular: Chest pain, palpitations, edema
● Gastrointestinal: Reflux (GERD-related cough), weight loss
● Neurological: Weakness, fatigue (e.g., in respiratory muscle diseases)
● ENT: Post-nasal drip, sinusitis
● General: Fever, chills, malaise, night sweats
�Summary and Clinical Impression
At the end of the history, summarize the key findings to guide your physical examination
and investigations.
�Optional: Special Considerations by Age
● Pediatrics: Birth history, immunization status, feeding, growth
● Geriatrics: Functional status, comorbidities, polypharmacy
RESPIRATORY SYSTEM EXAMINATION
PREPARATION
1. Wash hands
2. Introduce yourself, confirm patient details
3. Explain procedure and obtain consent
4. Position: Sitting upright; expose chest fully (preserve dignity)
GENERAL INSPECTION
- Observe from end of bed: distress, cyanosis, posture, breathing pattern
- Inspect environment: oxygen, inhalers, sputum pots
Hands and Arms
- Inspect: Clubbing, cyanosis, tar staining
- Palpate: Temperature, pulse, tremor (fine or flapping)
- Look for edema (suggests cor pulmonale)
FACE AND NECK
- Eyes: Anemia, Horner's syndrome
- Mouth: Central cyanosis, pursed lips
- Trachea: Midline or deviated
- JVP: Assess if raised
- Lymph nodes: Cervical, supraclavicular, axillary
CHEST EXAMINATION :
INSPECTION
- Chest shape: symmetry, deformities, scars
- Breathing pattern and effort
- Skin changes: lesions, scars
PALPATION
- Chest expansion: symmetrical?
- Tactile vocal fremitus: "99" test
- Apex beat: Shifted in lung hyperinflation
PERCUSSION
- Compare sides (anterior, lateral, posterior)
- Notes:
- Resonant = normal
- Dull = consolidation/collapse
- Hyperresonant = pneumothorax
- Stony dull = effusion
AUSCULTATION
- Compare all zones: anterior, lateral, posterior
- Breath sounds:
- Vesicular = normal
- Bronchial = consolidation
- Decreased = effusion/collapse
- Added sounds: crackles, wheezes, stridor, rubs
VOCAL RESONANCE
- Ask patient to say "ninety-nine"
- Increased = consolidation
- Decreased = effusion or pneumothorax
LOWER LIMBS
- Check for peripheral edema
- Signs of DVT: swelling, tenderness (risk of PE)
SUMMARY AND FURTHER STEPS
- Wash hands
- Summarize findings
- Consider further tests:
- SpO2, ABG, Chest X-ray, sputum culture, spirometry