1
Departments of Gastroenterology and Pulmonary Medicine
Sanjay Gandhi Postgraduate Institute of Medical Sciences (www.sgpgi.ac.in),
Lucknow 226014, India
Proforma for recording respiratory parameters in patients with achalasia
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Patient name:
Age (y):
Gender:
Date:
Symptoms & signs
Cough
Yes/ No
Duration (mo)
Dry/Productive
If productive, is it Mucoid/ Mucopurulent/ Purulent?
Nocturnal
Dyspnea
Yes/no
Yes/No
Duartion (mo):
NYHA grade:
Stridor: Yes/No
Wheeze: Yes/No
Chest pain
Yes/no
Pharyngeal symptoms
Yes/no
-Hoarsness
Yes/no
- Throat clearing
Yes/no
-Sore throat
Yes/no
Post-tussive emesis
Yes/no
Choking
Yes/no
Any other symptom?
General physical
Pallor / cyanosis / lymphadenopathy / jaundice / edema / clubbing /
examination
raised jugular venous pressure
Throat and tonsils
Respiratory system
Shape of the chest:
examination
Respiratory rate (per minute):
Use of accessory muscles: Yes/no
Auscultation: Breathe sound:
Chest
X-ray Date
(posteroanteriorview)
Findings
Intercostal retraction: Yes/no
Foreign sounds:
2
Past History: Recent pneumonia / tuberculosis / recurrent lower respiratory tract
infection / chronic lung disease / lung cancer
History of allergy: Yes/no
Family history of asthma / hay fever / eczema
History of sinusitis / nasal discharge / pain and tenderness over sinuses / headache /
recurrent cold
Other past history:
Smoking: Yes/No
Pack years:
Passive smoking: Yes/No
Pulmonary function tests:
Variables
Forced vital capacity (FVC)
Forced expiratory volume in 1 second (FEV 1)
Bronchodilator responsiveness (BDR; significant /
insignificant)
FEV 1 / FVC%
Peak expiratory flow rate (PEFR)
Maximum expiratory flow (MEF) 25-75%
Transfer coefficient (KCo)
Total lung capacity (TLC)
Residual volume (RV)
Impression:
HRCT (Thorax):
Actual Value
% of predicted