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

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Presentation on theme: "HISTORY Dr. Hesham Atef AbdelHalim Lecturer of Pulmonary Medicine Ain Shams University"— Presentation transcript:

1 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  Young age : Cystic fibrosis, Asthma, TB  Middle age:  Middle age: Infections, trauma, complications of cystic fibrosis, bronchiectasis and Asthma  Old age:  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 Farmer e.g. Farmer: EAA, Parasitic lung diseases…. Asbestos: Asbestos: Asbestosis Mining Mining: Silicosis, complicated TB

9  Residence  Near industrial areas / atmospheric pollutionAsthma,  Near industrial areas / atmospheric pollution : Asthma, Pneumoconiosis, Bronchogenic carcinoma, Mesothelioma. Pneumoconiosis, Bronchogenic carcinoma, Mesothelioma.  CrowdingPneumonia, TB  Crowding : Pneumonia, TB  Endemic areas/ ruralB, Hydatid, Filariasis  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  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:  Dramatic: seconds  Sudden: minutes - hours  Rapid: days  Gradual: weeks – months  Course  Progressive  Regressive  Intermittent  Stationary  Duration  Short  Long

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

15  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 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  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  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:  Type & color (frank, mixed or blood tinged)  Amount  Frequency  Last attack  Effect on general condition  Management / Blood transfusion

29  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 HaemoptysisHematemesis 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 NormalMelena Reaction to Litmus AlkalineAcidic 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:  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  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

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


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