Dr. Hesham Atef AbdelHalim Lecturer of Pulmonary Medicine HISTORY Dr. Hesham Atef AbdelHalim Lecturer of Pulmonary Medicine Ain Shams University http://telemed.shams.edu.eg/moodle5

Taking a patient’s history is the most important skill in medicine; it is the keystone of clinical diagnosis and the foundation for the doctor–patient relationship. The history will help you to formulate a differential diagnosis and focus your physical examination. As important, it will also help you in getting to know patients, winning their confidence and understanding the social context of their illness.

The consultation is best viewed as a ‘meeting of two experts’: the patient, an expert on the experience of illness and the unique context in which it has occurred, and the clinician, an expert on the diagnosis and management of illness.

The aims of history taking To identify the relevant organ system(s) responsible for symptoms. To clarify the nature of the pathological processes at play. To characterize the social context of patients’ illness, their concerns, their interpretation of symptoms, beliefs and attributions and any limitations of daily activities consequent upon their illness.

Components of Chest Case History Personal history Complaint History of present illness Cardinal chest symptoms Minor chest symptoms Past history Family history

Personal history Name Age Sex Marital history (+\- children) race Residence Occupation Habits of medical importance

Name : Familiarity Age Infancy: Congenital, metabolic diseases, histocytosis-X, cystic fibrosis, bronchiectasis, asthma. Young age: Cystic fibrosis, Asthma, TB Middle age: Infections, trauma, complications of cystic fibrosis, bronchiectasis and Asthma Old age: COPD, Bronchogenic carcinoma, Pulmonary embolism, pulmonary arteriosclerosis, aspiration pneumonia, lung abscess, viral infections, sleep apnea.

Sex Male: COPD, Bronchogenic carcinoma (sq. c.c., small c.c.), Occupational diseases Female: Pulmonary embolism, 1ry P++, Bronchial adenoma, adenocarcinoma, ILD (idiopathic or 2ry to c.t. diseases) Race TB (common in Negroes) Occupation e.g. Farmer: EAA, Parasitic lung diseases…. Asbestos: Asbestosis Mining: Silicosis, complicated TB

Marital status & children Residence Near industrial areas / atmospheric pollution: Asthma, Pneumoconiosis, Bronchogenic carcinoma, Mesothelioma. Crowding: Pneumonia, TB Endemic areas/ rural: B, Hydatid, Filariasis. Marital status & children Female: Deliveries, abortions, contraceptive pills, TB , salpingitis + menstrual history Male: TB epididymitis, S, CF, Kartagner’s and Young’s syndromes

Habits Smoking : Pack years = Number of cigarettes/day  Years 20 Alcohol : Aspiration, Lung abscess, Hypoventilation Drug addiction: Resp. depression, Septic embolism Bird breeder: EAA

Complaint Patient own words. + Onset Course Duration

Patient own words????? Try to define the main or the presenting symptom (the most distressing if more than one symptom) Or What symptom that made him come to hospital?

Onset: Course Duration Dramatic: seconds Sudden: minutes - hours Rapid: days Gradual: weeks – months Course Progressive Regressive Intermittent Stationary Duration Short Long

History of present illness Cardinal chest symptoms: Dyspnoea Cough Expectoration Haemoptysis Chest pain Chest Wheezes

Mediastinal compression Respiratory failure Corpulmonale Jaundice Minor chest symptoms: Toxemia Mediastinal compression Respiratory failure Corpulmonale Jaundice Cyanosis

History of present illness (cont’d) All symptoms should be analyzed as regards onset, course, and duration . All should be arranged chronologically Negative cardinal chest symptoms should be mentioned

The 6 Chest Cardinal Symptoms Dyspnea Cough Expectoration Hemoptysis Chest Pain Chest Wheezes

Dyspnea Dyspnea is a term used to characterize a subjective experience of breathing discomfort.

The cause of dyspnea may be either: Organic:( cardiac, chest, general). Respiratory Cardiac General causes Functional (e.g. exercise, emotion)

Dyspnea is clinically divided into: Exertional Mild, moderate or severe. At rest Orthopnea (advanced CHF, COPD or asthma- massive ascites, late months of pregnancy) Paroxysmal Cardiac / bronchial asthma Others?(e.g. Carcinoid, Uremic asthma)

Modified Medical Research Council Grading of dyspnea Modified Medical Research Council Dyspnoea Scale Grade  0 “I only get breathless with strenuous exercise”  1 “I get short of breath when hurrying on the level or walking up a slight hill”  2 “I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level”  3 “I stop for breath after walking about 100 yards or after a few minutes on the level”  4 “I am too breathless to leave the house” or “I am breathless when dressing”  NB: This is the modified MRC scale that uses the same descriptors as the original MRC scale in which the descriptors are numbered 1-5. The modified MRC scale (0-4) is used for calculation of BODE index.

Causes of acute dyspnea Cardiovascular system: Acute myocardial ischemia Congestive heart failure Cardiac tamponade Respiratory system: Bronchospasm Pulmonary embolism Pneumothorax Upper airway obstruction - aspiration, anaphylaxis Back

Cough Cough is the sudden and explosive forcing of air through the closed glottis. NB: There is no normal cough

Analysis of cough Dry or productive Dry: URTI, irritant inhalation Productive: Abscess, chronic bronchitis, pneumonia Timing: Morning Night No relation

Short or paroxysmal Short: URTI, Pleurisy Paroxysmal: FB, asthma Character e.g. Brassy: (cough with a metalic hard quality) intrathoracic tumors or aneurysm compressing on the trachea. Bovine: (a cough that lost its expulsive character and becomes prolonged with wheezing) affection of recurrent laryngeal nerve. Suppressed Croup Complications…….. Back

Expectoration Time. Amount. Color: Whitish: Bronchitis, asthma, acute pulm. edema. Yellowish: Purulent infections, eosinophilia. Greenish: Retained pus, pyocyaneous infection. Rusty: Pneumococcal pneumonia. Chocolate or anchovy sauce: Amoebic abscess Red current jelly: Freidlander pneumonia, mycoplasma pneumonia, bronchogenic carcinoma. Black: Coal worker pneumoconiosis. Grey: Admixture with carbon as in town dwellers. Pink: Acute pulmonary congestion.

Aspect (consistency): Odour. Aspect (consistency): Watery: acute pulmonary edema, rupture of hydatid cyst. Viscid Mucoid Mucopurulent Purulent Relation to posture Related: Localized bronchial disease. Not related: Generalized bronchial disease. Back

Haemoptysis Definition: Coughing of blood Analysis: Amount Frequency Type & color (frank, mixed or blood tinged) Amount Frequency Last attack Effect on general condition Management / Blood transfusion

Life threatening: If more than 150cc Causes: Massive: If more than 200 to 600ml within 24 hrs or 400 ml within 3 hrs. Life threatening: If more than 150cc (which equals the anatomical dead space) Causes: TB Bronchiectasis Mycetoma Bronchogenic carcinoma Lung abscess Necrotizing pneumonia Vascular anomalies False (spurious) or true: Above or Below vocal cords

Haemoptysis Hematemesis History Chest or cardiac disease Dyspepsia, vomiting, alcoholism Blood Bright red, with froth of sputum Coffee ground, + food particles Sputum Remains blood tinged for few days after attack No sputum Stool Normal Melena Reaction to Litmus Alkaline Acidic Examination Evidence of chest or cardiac disease Epigastric tenderness or liver cirrhosis, splenomegaly

DD of Haemoptysis (most common causes) Acute/ chronic bronchitis TB MS Lung abscess, Bronchiectasis Bronchogenic carcinoma/ adenoma Pulmonary infarction Back

Chest Pain Analysis: Onset, course & duration Site Character Severity Reference / Radiation What precipitates & what relieves Associated symptoms

Causes of Chest Pain Respiratory: Cardiac: Pulm. embolism pneumothorax Pleurisy Tracheitis, bronchitis, pneumonia Mediastinal (Tumors, enlarged LNs) Cardiac: Angina Myocardial infarction Mitral valve prolapse Pericarditis Dissecting aortic aneurysm Aortic stenosis / HOCM

Others: Chest wall: GIT: Trauma (recent or healed # rib) Tietze `s syndrome Herpes zoster Osteoporosis GIT: Reflux (GERD) Esophageal spasm Peptic ulcer Gastritis, oesophagitis pancreatitis Others: Breast tenderness Anxiety

DD Acute onset chest pain: Coronary Artery Disease Pulmonary embolism / infarction Pneumothorax Pleurisy / Pericarditis Dissecting aortic aneurysm Esophageal spasm Back

Chest Wheezes Definition: Sound of breathing Could be inspiratory, expiratory, or both

Analysis: Time Duration Frequency Severity What Precipitates ? What relieves ? Response to usual medication Condition between attacks Hospitalization Associated symptoms

Causes of Chest Wheezes Obstructive diseases e.g upper airway obstruction, bronchial asthma, COPD Restrictive diseases e.g. EAA, Eosinophilia Pulmonary vascular diseases Tumors of lung Infectious lung diseases Miscellaneous e.g. FB, drug-induced, Carcinoid Back

Minor chest symptoms Chronic toxemia Corpulmonale: DD of LL edema in chest case Mediastinal compression Dyspnea, Dysphagia, hoarseness of voice, brassy cough, edema of face or eye lid or neck swelling Respiratory failure Hypoxia: Cyanosis, irritability, lack of concentration, fine tremors, tachycardia. Hypercapnia: Headache, flappy tremors, drowsiness, disturbed sleep rhythm. Cyanosis Jaundice: DD of jaundice in chest case

Past history Similar conditions DM, HTN, Bilharziasis. Fever hospital or sanatorium admission or anti TB. Surgery or blood transfusion. Drug allergy. Vaccination. Trauma. FB inhalation

Family history Similar disease in the family. Chest diseases in family e.g. TB, Bronchial asthma,…… Important diseases in the family e.g. DM, HTN Atopy Consanguinity