1. Dr. Hesham Atef AbdelHalim Lecturer of Pulmonary Medicine
HISTORY
Dr. Hesham Atef AbdelHalim
Lecturer of Pulmonary Medicine
Ain Shams University

2. 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.

3. 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.

4. 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.

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

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

7. 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.

8. 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

9. 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

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

11. Complaint
Patient own words. +
Onset
Course
Duration

12. 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?

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

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

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

16. 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

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

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

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

20. 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)

21. 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.

22. 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

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

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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. 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

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

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

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

38. 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

39. 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

40. 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

41. 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