- •Inquiry (interrogatio)
- •Personal details (identification data)
- •Patient’s complaints
- •History of present illness (anamnesis morbi)
- •Personal history (anamnesis vitae)
- •Family History and Heredity
- •Dietary History and Habits
- •Gynaecological History
- •Past Medical History
- •Allergological History
- •Sanitary-and-Epidemiological History
- •Ecological History
- •Occupation History
- •System review
- •Respiratory System
- •Cardiovascular System
- •Inspection
- •Gastrointestinal System
- •Inspection
- •Urinary System
- •Inspection
- •Endocrine System
- •Nervous System
System review
Respiratory System
SPECIAL INSPECTION
Voice: not changed (sonorous) quiet hoarseness aphonia muteness
Breath: through nose mouth
Nose external configuration normal abnormal (pinched, saddle nose)
septum in the midline deviation (right, left) perforation
congestion discharge polyps
breath through the nose: free difficult absent
tenderness of paranasal sinuses: present absent frontal maxillary
Trachea: position (midline or deviated), tracheal tug.
Chest
Shape epigastric angle <90° =90° >90°
Physiological normosthenic asthenic hypersthenic
Pathological emphysematous/barrel-shaped paralytic keeled/pigeon funnel scaphoid kyphoscoliotic
Symmetry of the chest
Chest wall deformity places of retraction expansion
Symmetry of halves of the chest enlargement reduction right left half
clavicles are at the same various level
shoulder blades are at the same various level
supraclavicular fossae are expressed equally uneven from both sides
subclavicular fossae are expressed equally uneven from both sides
reduction smoothness of intercostal spaces
Chest wall movements decreased increased normal
both halves of thorax equally unequally participate in breathing
Sites and description of any abnormality _________________________________
____________________________________________________________________
____________________________________________________________________
Respiration rate is _____ per minute
Rhythm rhythmical arrhythmic
Type of respiration thoracic abdominal mixed
Depth of respiration normal superficial deep
Involvement of the accessory respiratory muscles in the breathing act
mm. sternocleidomastoideus trapezius pectoralis major pectoralis minor
Girth of chest: on quiet breathing _____ cm
on deep breathing in _____ cm
on breathing out _____ cm
Respiratory excursion of the chest is _____ cm.
PALPATION
Painless tenderness local profuse of the chest
Elastic rigid
Vocal (tactile) fremitus
not changed equal unequal on symmetrical points of chest surface
Pleural friction
Sounds of fluid in the pleural cavity
Sites and description of any abnormality _________________________________
____________________________________________________________________
PERCUSSION
Comparative percussion
Resonant/clear/pulmonary tympanic dull blunted bandbox percussion note over the entire lung surface
Area of any abnormality ________________________________________________
____________________________________________________________________
____________________________________________________________________
Topographic percussion
The position of upper levels of lung apices:
|
Anteriorly |
Posteriorly |
Right |
___ cm above clavicle |
at the level of spinous process of the _____ th cervical vertebra |
Left |
___ cm above clavicle |
at the level of spinous process of the _____ th cervical vertebra |
The width of the right Kronig’s isthmus is ___ cm
the width of the left one is ___ cm.
The position of lower borders of lungs:
Topographical lines |
Right lung |
Left lung |
Parasternal line |
lower edge of the _____ th rib |
- |
Midclavicular line |
lower edge of the _____ th rib |
- |
Anterior axillary line |
lower edge of the _____ th rib |
lower edge of the _____ th rib |
Midaxillary line |
lower edge of the _____ th rib |
lower edge of the _____ th rib |
Posterior axillary line |
lower edge of the _____ th rib |
lower edge of the _____ th rib |
Scapular line |
lower edge of the _____ th rib |
lower edge of the _____ th rib |
Paraspinal line |
at the level of spinous process of the _____ th thoracic vertebra |
at the level of spinous process of the _____ th thoracic vertebra |
The respiratory mobility of the lower border of lungs:
Topographical lines |
Right |
Left |
Midclavicular line |
_____ cm |
- |
Midaxillary line |
_____ cm |
_____ cm |
Scapular line |
_____ cm |
_____ cm |
AUSCULTATION
Character and intensity of basic breath sounds:
Vesicular bronchovesicular bronchial
Vesicular diminished increased puerile harsh cogwheel absence
Bronchial physiological in the parts of its auscultation
pathological increased decreased amphoric stenotic metallic
Relative duration of inspiration and expiration
Sites of any abnormality ________________________________________________
____________________________________________________________________
Adventitious sounds not auscultated
Dry rales sibilant sonorous
Moist (humid) rales crackles crepitation coarse/large bubbling medium fine/small consonating/sonorous non-consonating/non-sonorous
Sites of any abnormality ________________________________________________
____________________________________________________________________
Pleural friction rub
Vocal resonance not changed equal unequal on symmetrical points
intensified decreased absent
Sites and description of any abnormality ________________________________
____________________________________________________________________
FUNCTIONAL TESTS OF RESPIRATION DELAY
Timed inspiratory capacity (Shtange test) _______ sec
Timed expiratory capacity (Gencha test) _______ sec