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