HISTORYDr. 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 takingTo 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 historyNameAge SexMarital history (+\- children) raceResidenceOccupation Habits of medical importance
Name : Familiarity Age
Infancy: Congenital, metabolic diseases, histocytosis-X, cystic fibrosis, bronchiectasis, asthma.
Young age: Cystic fibrosis, Asthma, TBMiddle age: Infections, trauma, complications
of cystic fibrosis, bronchiectasis and AsthmaOld 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 diseasesFemale: Pulmonary embolism, 1ry P++, Bronchial
adenoma, adenocarcinoma, ILD (idiopathic or 2ry to c.t. diseases)
RaceTB (common in Negroes)
Occupation
e.g. Farmer: EAA, Parasitic lung diseases….
Asbestos: Asbestosis
Mining: Silicosis, complicated TB
Residence Near industrial areas / atmospheric pollution: Asthma,
Pneumoconiosis, Bronchogenic carcinoma, Mesothelioma.
Crowding: Pneumonia, TBEndemic areas/ rural: B, Hydatid, Filariasis.
Marital status & childrenFemale: Deliveries, abortions, contraceptive pills,
TB , salpingitis + menstrual history Male: TB epididymitis, S, CF, Kartagner’s and
Young’s syndromes
HabitsSmoking :
Pack years = Number of cigarettes/day Years
20Alcohol : Aspiration, Lung abscess,
Hypoventilation Drug addiction: Resp. depression, Septic
embolismBird 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: Dramatic: secondsSudden: minutes - hoursRapid: daysGradual: weeks – months
CourseProgressiveRegressiveIntermittentStationary
DurationShort Long
Cardinal chest symptoms: Dyspnoea Cough Expectoration Haemoptysis Chest pain Chest Wheezes
History of present illness
Minor chest symptoms:ToxemiaMediastinal compressionRespiratory failureCorpulmonaleJaundiceCyanosis
History of present illness (cont’d)
All symptoms should be analyzed as regards onset, course, and duration .
All should be arranged chronologicallyNegative cardinal chest symptoms should
be mentioned
The 6 Chest Cardinal Symptoms
Dyspnea Cough
Expectoration Hemoptysis
Chest Pain Chest Wheezes
Causes of Chest PainRespiratory:
Pulm. embolism pneumothorax Pleurisy Tracheitis, bronchitis, pneumonia Mediastinal (Tumors, enlarged LNs)
Cardiac:AnginaMyocardial infarctionMitral valve prolapsePericarditisDissecting aortic aneurysmAortic stenosis / HOCM
Chest wall: 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 DiseasePulmonary embolism / infarctionPneumothoraxPleurisy / Pericarditis Dissecting aortic aneurysmEsophageal 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 diseasesTumors of lung Infectious lung diseasesMiscellaneous e.g. FB, drug-induced, Carcinoid
Back
Minor chest symptoms Chronic toxemia Corpulmonale: DD of LL edema in chest case
Mediastinal compressionDyspnea, 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 conditionsDM, 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,
HTNAtopyConsanguinity