CASE SHEET – RESPIRATORY SYSTEM

NAME:

AGE: SEX:

ADDRESS:

OCCUPATION:

GENERAL EXAMINATION:

Posture and attitude: Normal

Body build and nourishment: Moderately built and moderately nourished

Pallor: No Pallor

Icterus: No icterus

Cyanosis: No cyanosis

Clubbing: No clubbing

Lymphadenopathy: No lymphadenopathy

Edema: No edema

Skin, hair and nails: Normal

Other features:

Gait: Normal

Thyroid swelling: No thyroid swelling

Varicosity of veins: No varicosity of veins

VITAL SIGNS:

ARTERIAL PULSE:

1. RATE:
2. RHYTHM : Regular
3. VOLUME: Normal
4. CHARACTER: Normal
5. CONDITION OF VESSEL WALL: No vessel wall thickening
 6. RADIOFEMORAL DELAY: No radiofemoral delay
7. Other peripheral pulsations: All peripheral pulsations are normal and equally felt on
both sides

BLOOD PRESSURE: / mm Hg in Right arm in sitting position

RESPIRATION:
Rate:
Rhythm:
Type:
TEMPERATURE: Clinically afebrile

EXAMINATION OF RESPIRATORY SYSTEM:

A) INSPECTION
1. Nasal alae: No movement
2. Position of trachea: Trachea appears to be in central in position
3. Shape of Chest: Normal and bilaterally symmetrical
4. Respiratory movement:
Rate:
Rhythm:
Type:
5. Movement of chest wall: Equal on both sides
6. Apex beat : Visible/Not visible

B) PALPATION
1. Position of trachea: Central
2. Position of apex beat: Palpable in the left 2nd intercostal space 1cm medial to
the midclavicular line
3. Movement of chest wall: Normal and equal on both sides
4. Expansion of chest: __cm
5. Tactile vocal fremitus
Supraclavicular area
Infraclavicular area
Mammary area
Axillary area Normal and equal on both sides
Infra axillary area
Suprascapular area
Infrascapular area
 Interscapular area
C) PERCUSSION

1. LUNG AREAS
Supraclaviclar area
Infraclavicular area
Mammary area
Axillary area Normal resonance is obtained and
Infra axillary area equal on both sides
Suprascapular area
Infrascapular area
Interscapular area

2. Liver dullness is obtained in right 5th intercostal space in the midclavicular

line
3. Cardiac borders
LEFT BORDER corresponds to apex beat
RIGHT BORDER corresponds to right sternal border
UPPER BORDER – Left 2nd intercostal space is resonant
LOWER BORDER – Cannot be determined by percussion

D) AUSCULTATION

1) Breath sounds
Supraclavicular area
Infraclavicular area
Mammary area Normal vesicular breath sounds with
equal intensity on both sides
Axillary area
Infra axillary area
Suprascapular area
Infrascapular area
Interscapular area

2) Vocal resonance
Supraclavicular area
Infraclavicular area
Mammary area Normal and equal on both sides
Axillary area
 Infra axillary area
Suprascapular area
Infrascapular area
Interscapular area

3) Adventitious sounds:
No rhonchi
No crepitations
No pleural rub
No rales

REPORT:
On examination, the respiratory system of the given subject is within normal limits.