1. HISTORY TAKING Dr. Don Gregory 1 st year Junior Resident Dept. of TB & Chest Diseases Govt. Medical College, Patiala

2.  The HISTORY is a record or recitation of the patient’s symptoms  In diagnosis,the medical history is all- important,frequently surpassing in its diagnostic importance even a thorough physical examination  History taking is an art.The ability to elicit a good history comes with years of experience and knowledge  History taking helps to form a healthy Doctor- patient relationship  It also builds up the patient’s confidence and trust in his doctor

3.  Affords a lead in the right direction/clue to diagnosis  Eliminates certain diagnostic possibilities  Suggests further avenues of investigation  Helps to focus on system involved  Earlier proof of disease,since symptoms usually precede signs

4.  The consulting room should be quiet and free from Interruptions  Introduce yourself and clarify your role, giving the patient an outline of what your intentions are  Ensure the patient is comfortable.  Listen to the patient, not merely hear  Maintain Confidentiality with the patient  Allow patient to recite in his own unhurried way  Have a elasticity in interrogation  Every symptom to be analysed thoroughly  Leading questions to elicit symptoms omitted by patient

5.  Preliminary data of the patient  Chief complaints  History of presenting illness  Past history  Treatment history including ATT  Family history  Personal history  Menstrual history

6. Name of patientFor establishing rapport Father’s nameHelps to differentiate two patients with same name AgeHelps to include or r/o certain diagnostic possibilities because of age trends of certain diseases.eg: Congenital anamolies are common in childhood. Degenerative, neoplastic, vascular ailments are more common in middle aged or elderly young age-cystic fibrosis,BA,TB Middle age-infections,BA Old age-COPD,lung cancer,pulmonary embolism. SexIHD, hemophilia, bronchogenic carcinoma have more affinity for male sex. Thyroid disorders,mammary cancers, autoimmune disorders are more in females

7. Religion  Sikhs do not smoke and are less likely to develop symptoms related to smoking  Muslims do not consume alcohol & are less likely to develop symptoms related to alcoholism  Certain sects of Hindus do not consume meat products and are less prone to develop CA colon Complete address  Helps to know environmental factors /endemic factors eg: people from urban areas are prone to develop problems related to urbanization, people from hilly areas more prone to develop goitre, primary pulmonary HTN  For follow up  Helps tracing patient in case of default  Endemic diseases like filariasis,hydatid  Industrial area/environmental pollution leading to BA,pneumoconiosis,broncogenic ca,mesothelioma HandednessImportant in CNS disorders

8.  These are complaints for which patient comes to visit the doctor  If patient is not in a position to give history (moribund, has loss of speech, in coma, mental illness )then it has to be asked with patient’s relative/attendant  These complaints should be recorded in a chronological order along with duration of the symptoms e.g: cough-3 months Fever -1 month hemoptysis-3 days

9.  Its elaboration of chief complaints  Symptoms are studied,analysed and recorded  History is taken under the following headings: Onset of the symptom, Duration and progression, Type, Diurnal and postural variation, Aggravating and relieving factors, Associated symptoms

10.  Depending on which system or systems are involved on the basis of patient’s history, specific interrogation is done with a view to elicit maximum information about that system.eg:If patient has h/o cough, hemoptysis then suspicion would fall on respiratory system involvement and questioning is directed towards its other related symptoms.  Symptoms related to other systems is enquired to include or rule out multisystem involvement (Negative History extraction)

11. Patient should be asked about any previous intake of ATT.If yes, following questions are asked:  Source from where drugs taken?  Sputum microscopy and its results/reports?  Any X-ray done?  Type of treatment taken and its duration?  Sputum microscopy result at the end of treatment?  Cause of irregularity in t/t if any?

12. This includes a review of: Any history of similar illness in the past Any past illness with a pointed reference to entities like Rheumatic fever, IHD Any H/o DM/HTN/asthma/epilepsy Any H/o childhood illness of exanthematous fevers eg:chicken pox,measles Any H/o traumatic lesions-pleural thickening can be a result of chest trauma. Any H/o surgical intervention Any H/o blood transfusions and if any reactions Any H/o drug reactions/allergies Any H/o sexual exposure Countries of residence/travel : certain diseases like malaria, ankylostomiasis, amoebiasis and kala azar are more prevalent in the tropics and subtropics animal exposure: pigeons-cryptococcaus,chicken-histoplasmosis,parrots-pisstacosis,sheep-Q fever

13. Importance of extracting an accurate past history  The existing illness may be related to or be a sequel of some past illness such as TB, Rheumatic fever,IHD, syphilis, encephalitis or meningitis  History of asthma, malaria,gout, epilepsy, amoebiasis, urticaria have a tendency to relapse/recurrence  Complications of uncontrolled states of DM, HTN can occur  HIV infection can cause opportunistic infections If any past illness is present, enquiry is to be done regarding treatment received

14.  This should include all previous medical and surgical treatment  Details of drugs taken including analgesics,psychotropic drugs and of previous surgery and radiotherapy  Any drug allergy/ untoward reaction if occurred is to be enquired regarding its nature and severity so that same medication can be avoided in the patient in the future  Any medication that the patient may be continuing to take to the present date need to be asked to avoid any adverse drug reactions when new drugs are introduced

15.  H/o intake of OCP and antiepileptics needs to be enquired  History regarding any long term anticoagulant therapy need to be asked  Antibiotics like macrolides and quinolones in recent past warrants use of different class of antibiotics  History regarding use of steroids need to be asked with its duration and dosage.

16.  The family history affords information about the genotype or ”Inherited make-up” of the patient  Knowledge of an illness in the family can lead to early detection and treatment  Information about the immediate family may also have considerable bearing on the patient’s symptoms. Enquiry should be made regarding disease state in family members,any early deaths in family  Disease in several members of family can be due to inheritance, contact, contagiousness or common environmental factors  When there is suspicion of a familial disorder, it is helpful to construct a family tree. If the pattern of inheritance suggests a recessive trait, ask whether the parents were related – in particular whether they were first cousins  Common diseases expressed in families include Hyperlipidaemia (IHD), DM, HTN, asthma, Myopia, Alcoholism, Depression, Osteoporosis, cancers, etc

17.  Education Gives information regarding highest degree attained Helps to know the age at which patient left school Helps in assessing diseases and disorders causing intellectual deterioration and social function  Occupation Helps to assess his economic status Frequent job changes or chronic unemployment may reflect both socioeconomic circumstances and the patient’s personality Gives a clue to exposure to Occupational hazards eg Farmers-EAA,moulds,parasitic lung disease Mining-silicosis,complicated TB Other non organic exposures like coal,asbestos lead to pneumoconiosis. Other problems such as depression, chronic fatigue syndrome and general malaise may also be blamed on working conditions Presence of a disease may make patient unfit for his occupation eg: salmonella infection in food handlers, epilepsy/colour blindness in drivers of public transport

18.  Marital History Enquiry is made regarding consanguinity, duration of marriage, health of spouse,no. of children Infertility may give a clue to the presence of immotile cilia disorder, CF,genital TB Developmental anomalies in offspring is enquired  Social history-pets for HP  Housing Housing conditions, no of family members, water facilities,sanitation Overcrowding can be a cause for TB, pneumonia.  Appetite  Sleep  Bowel and bladder regularity

19.  Sexual behaviour  Enquiry Important mainly in long distant truck drivers  h/o STD and HIV need to be enquired  Habits Enquire h/o smoking/alcohol/tobacco/drug abuse  If smoker,calculate pack years or smoking index Pack yr=no.of cigarette packs smoked per day*no.of yrs smoking index=no.of cigarettes smoked per day*no.of yrs A pack year of >40 OR smoking index of >400 is a risk for Bronchogenic carcinoma Chullah exposure and passive smoking in females must be asked for.  If alcoholic, calculate units of alcohol consumed. 1 unit is equal to 1/2 a pint of beer/ 1 glass of sherry/ 1 glass of wine/1 standard measure of spirits + Alcoholics are more prone for aspiration, lung abscess,hypoventilation. + Drug addicts may develop HIV,hepatitis,septic embolism,respiratory depression.

20.  Age of menarche  Menstrual cycle :  no of days of bleeding  duration of cycle,  associated pain and  regularity of cycles  Any menstruation related chest pain : R/o pulmonary endometriosis  Any h/o amenorrhoea : R/o pregnancy  Obstetric history

21.  Cough  Breathlessness  Chest pain  Hemoptysis  Fever  Hoarseness of voice  Hiccups

22. + Cough is a sudden and variable expiratory thrust of air from the lungs and through the air passages,associated with phonation,which momentarily interrupt the physiological pattern of breathing + Its a defense mechanism of the body to keep lower respiratory passages clear + The cough begins with a rapid inspiration, followed in rapid sequence by closure of the glottis, contraction of the abdominal and thoracic expiratory muscles, abrupt increase in pleural and intrapulmonary pressures, sudden opening of the glottis and expulsion of a burst of air from the mouth.The high intrathoracic pressures which often exceed 100 to 200 mmHg, increase the velocity of airflow through the airways, hastening the propulsion of the offending particles and producing the sound of a cough by setting into vibration airway secretions, the tracheobronchial walls, and the adjacent parenchyma AFF:CN V(nose,sinuses),IX(post.pharynx),X(pericardium),phrenic. CENTRE:Medulla EFF:spinal motor(exp muscles),CN X(larynx,trachea,bronchi),phrenic N

23. 1) Infections of respiratory tract: acute (laryngitis,tracheitis),chronic(Pulm TB,Bronchiectasis) 2) Mechanical irritation of respiratory tract:FB,inhalation of irritant gases,bronchogenic carcinoma 3) Reflex causes:irritation of vagus,FB/wax in EAC 4) Extrapulmonary causes:these induce cough through pressure on trachea/bronchus,infiltration of resp tract or secondary involvement of lung parenchyma eg:diseases of pleura,diaphragm or esophagus,aortic aneurysm,MS,LVF 5) Psychogenic 6) Drug induced:ACE Inhibitors

24. 1) Onset  Sudden:asthma,FB,inhalation of irritant gases  Insidious:pulmonary TB 2) Dry or productive  Dry:URTI,inhalation of tobacco smoke,early PTB  Productive:CB,lung abscess,bronchiectasis 3) Severity  Mild  Irritating/disturbs sleep at night 4) Character  Dry and irritable,max on waking up:early PTB  Paroxysmal:Bronchial asthma,cardiac failure,whooping cough  With wheeze:Bronchial asthma,CB,tropical eosinophilia  Barking(harsh,loud,seal like):acute LTB,hysteria  Bovine(cough loses its explosive character&becomes prolonged& wheezing): D/t involvement of RLN by tumours  Staccato(paroxysm ends in a stridulous inspiration):pertusis  Brassy/metallic:mediastinal tumour/aortic aneurysm

25. 5)Associated pain/distresspleurisy, pneumonia, rib fracture 6)Diurnal variation  Early morning:COPD,PTB,bronchiectasis,allergy  Nocturnal:asthma,pulmonary edema,chronic sinusitis,diaph.hernia 7)Postural variation/relief  I/L side:pleurisy,pleural effusion  C/L side:lung abscess  Sitting:LVF,COPD,diaphr.hernia 8)Relation to meals  Increases on deglutition:developmental anamoly(BEF,TEF)  Increases after meals:chronic lung disease 9)Associated features  Cough syncope:chronic airway obstruction  Dysphagia:pressure on esophagus  Change of voice:pressure on trachea/main bronchus  Fever:PTB,pneumonia,lung abscess, UTI

26.  Respiratory tract of normal adult produces 100 ml of sputum per day  If excess mucus is produced, its coughed out as sputum 1)Quantity Scanty(< ¼ cup): URI Copious( >¼ cup): CB,lung abscess,bronchiectasis,PTB 2)Colour Yellow:due to pus/leucocytes Green :pseudomonas infection Rusty:pneumonia Pink,frothy:pulmonary edema Dark brown:amoebic liver abscess,lung fluke infection 3)consistency  Thin watery: Pulmonary edema  Thick viscid: asthma,CF  Casts: ABPA,asthma, CB, CF

27. 4)Foul smellBronchiectasis,lung abscess, gangrene, malignant growth, bronchopleural fistula 5) Diurnal variationEarly morning: asthma 6) Postural variationSeen in lung abscess,bronchiectasis 7)HemoptysisFrank blood:TB Streaks of blood:TB, Chronic bronchitis 8)Presence of foreign body Bronchial Casts seen in ABPA, Asthma Hooklets of hydatid Sulfur granules of actinomycosis

28. + Dyspnea comes from the Greek word for hard breathing + It is the undue unpleasant subjective awareness of one’s own breathing characterized by increased respiratory effort and associated with distress,discomfort or shortness of breath/air hunger + Often described as shortness of breath + Its different from tachypnea which refers to increased ventilation in proportion to increased metabolism or hyperventilation when increased ventilation is in excess of metabolic needs

29. GRADEMedical Research Council (MRC) classification New York Heart Association(NYHA) classification I Not troubled by Breathlessness except on strenuous exercise No dypsnoea with ordinary activity II Shortness of breath when hurrying or walking up a slight hill Slight limitation of physical activity. Comfortable at rest III Walks slower than his contemporaries on the level/ stops for breath when walking at his own pace Marked limitation of physical activity/less than ordinary physical activity will lead to dypsnoea IV Stops for breath after about 100 mtr or after a few minutes on the level Inability to carry out any physical activity without discomfort. Dypsnoea present even at rest V Too breathless to leave the house/breathless when dressing or undressing

30. 1) Dypsnoea on exertion  Obstructive airway diseases:asthma,COPD, CB  Restrictive lung diseases:pulmonary fibrosis  Early heart disease: IHD, mitral stenosis  Arrythmia,anxiety,obesity hyperdynamic states 2)Dypsnoea at rest Acute infections/mechanical conditions:pneumothorax,pneumonia,pleural effusion Paroxysmal dypsnoea: acute LVF,asthma Metabolic causes:acidosis of uremia or diabetes Hyperthyroidism

31. ORTHOPNEA  Its dypsnoea in supine position  Occur within 30 seconds due to increase in left atrial pressure  Causes include cardiac failure,decreased vital capacity seen in severe MS, pulmonary HTN TREPOPNOEA  Dypsnoea in any of recumbent positions not due to CHF  In cardiomegaly,patient feels discomfort in left lateral recumbent position PLATYPNOEA  Dypsnoea in upright position,relieved on recumbency  Seen in left to right intracardiac pulmonary vascular shunting of blood,pneumonectomy, constrictive pericarditis PAROXYSMAL NOCTURNAL DYPSNOEA  Dypsnoea at night which awakes the patient from sleep gasping for air& he sits or stands to catch his breath  Suggests cardiac cause of dypsnoea. Eg: LVF

32. 1) Onset  Acute:asthma,pulmonary edema,pneumothorax,FB etc  Chronic:COPD,pleural effusion etc 2) Time course  Minutes:pneumothorax,pulmonary embolism, FB,pulm.edema due to arrythmia, laryngeal body,asthma  Hours: LVF, Pneumonia  Days: LVF,pneumonia  Weeks: pleural effusion,anemia,tumours  Months:pulmonary fibrosis,muscle weakness  Years: COPD, chest wall disorders 3) GradingMRC/ NYHA grade 4)RecurrenceSeen in bronchial asthma 5)H/o orthopnea, PNDSuggests cardiac origin 6)Associated features  Fever:suggest infective cause eg:pneumonia, PTB  Wheeze: asthma,acute exacerbation of COPD  Cough:asthma, PTB, bronchiectasis  Pedal edema:cardiac failure, anemia  Joint pain:ILD secondary to RA  Skin lesions: seen in SLE, scleroderma

33. + h/o seasonal variation + Occupational history + Drug history

34. + Pain is an unpleasant perception caused by stimulation of sensory end organs and efferent tracts + Anterior thoracic pain is one of the commonest and most important symptoms of cardiovascular and respiratory diseases + Causes include thoracic,intrathoracic and extrathoracic causes

35. 1) Onset Acute: pulmonary embolism, MI,pericarditis, trauma 2)Site  Substernal :Angina, MI  Lateral chest wall: pleurisy  Anterior chest:aortic dissection  Epigastrium: peptic ulcer disease  Localised pain: rib fracture,tumours involving pleura/rib  In distribution of thoracic nerves:Herpes zoster 3)Type  Pressing, constricting,vice-like heaviness in angina  Sharp,severe pain aggravated on coughing & inspiration in pleurisy  Constant, boring pain in aortic aneurysm & malignant tumours of mediastinum  Severe tearing pain in dissecting aneurysm  Dull poorly localised central chest pain in large central tumours

36. 4)Radiation of pain Pain of angina/ MI radiates to left shoulder/arm, neck or jaw Pain of aortic dissection radiate to interscapular region 5) Referred painCentral diaphragmatic inflammation pain is referred to tip of shoulder and of lateral part to lower lateral chest wall and abomen 6) Aggravating factors  Exercise,excitement in angina  Coughing,inspiration, lying on same side in pleuritic pain  Swallowing in esophageal disorders  Coughing,sneezing,straining in musculoskeletal pain  Coughing,swallowing, twisting trunk in pericarditis 7)Relieving factors  Nitrates relieve pain in angina  Pericarditis pain abated by leaning forward in sitting posture 8)Duration of pain anginal pain lasts usually for few seconds Pain of neurocirculatory asthenia lasts hours to days 9)Associated features  sweating,dypsnoea in MI  Hemoptysis in pulmonary infarction  Fatigue,palpitation in MVP

37. + It is the coughing out of blood + Its a indicator of serious disease of respiratory tract + Can be confused with hemetemesis + Coughed up blood is usually bright red and frothy whereas Vomited blood is usually clotted, darker, non frothy, contains food particles and acid in reaction. + Haemoptysis originates from bronchial arteries( 95%) or pulmonary arteries(5%) + Massive haemoptysis is coughing more than 400ml in 3 hrs or 600 ml blood within 24 hours.seen in TB, Bronchiectasis,CB, bronchogenic carcinoma

38. + Infections + Bronchitis + Tuberculosis + Fungal infections + Pneumonia + Lung abscess + Bronchiectasis + Neoplasms + Bronchogenic carcinoma + Bronchial adenoma + Cardiovascular disorders + Pulmonary infarction from thromboembolism + Mitral stenosis + Trauma + Foreign body + Hematologic/immunologic + Blood dyscrasia + Goodpasture’s syndrome

39. + Massive hemoptysis- TB,bronchiectasis,broncogenic ca,suppurative pneumonia,thromboembolism. + Scanty hemoptysis-broncogenic ca,chronic bronchitis,thromboembolism + Hemoptysis with streaks-bronchiectasis,chronic bronchitis,pneumococcal + Recurrent hemoptysis-broncogenic ca,chronic bronchitis,TB,bronchiectasis

40. 1)Age  Childhood and adults: Bronchiectasis, TB, MS  Middle and old age: bronchogenic carcinoma 2) Quantity  Mild: early PTB, acute/chronic bronchitis  Profuse:advanced PTB, MS, bronchogenic CA, 3)Presence of sputum  Blood is mixed with sputum in infectious causes  Fresh blood without sputum in non infective causes 4)H/o trauma  eg: gun shot wounds / fracture of ribs 5) Associated symptoms  Cough. fever.,night sweats,loss of wt in TB  H/o Recent operation/phlebitis in pulm infarction  Dypsnoea, palpitation in Mitral stenosis  Bleeding from other sites is s/o blood dyscrasias  H/o smoking in old age is s/o bronchogenic CA  Cough with foul smelling sputum s/o lung abscess

41. + The mean oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels at 6 a.m. and higher levels at 4-6pm + The maximum normal oral temperature is 37.2°C (98.9°F) at 6 a.m. and 37.7°C (99.9°F) at 4 p.m + Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings + Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point + An a.m. temperature of >37.2°C (>98.9°F) or a p.m. temperature of >37.7°C (>99.9°F) defines a fever

42. + A fever of >41.5°C (>106.7°F) is called hyperpyrexia. This extraordinarily high fever can develop in patients with severe infections but most commonly occurs in patients with central nervous system (CNS) haemorrhages + Hyperthermia is characterized by an uncontrolled increase in body temperature that exceeds the body's ability to lose heat. The setting of the hypothalamic thermoregulatory centre is unchanged

43. 1)Onset of fever  Sudden: Pneumonia, URI  Gradual: Typhoid fever 2) Severity of fever  Mild grade: 99-100F  Moderate grade: 100-103F  High grade: >103F  Hyperpyrexia: >106.7F 3) Type  Remittent: Temperature does not touch normal at all and the diurnal variation exceeds 1.5F eg: typhoid, Infective endocarditis  Continuous: Temperature does not touch normal at all but the diurnal variation is less than 1.5F eg: pneumonia, typhoid, UTI  Periodic/Relapsing: Here fever occurs in bouts lasting for days with afebrile phases eg:brucellosis, hodgkins lymphoma  Intermittent/septic/hectic: Here fever remains for few hours and then temperature touches baseline. Its of 3 types

44.  Quotidian: intermittent fever that occurs daily  Tertian: intermittent fever on alternate days  Quartan: intermittent fever on every 4 th day 4) Associated chills and rigors Seen in lobar pneumonia, malaria, pyelonephritis, malaria, sepsis,infective endocarditis 5) Relieved with antipyretics? Hyperthermia is not relieved by antipyretics 6)Associated features  h/o evening rise of temperature: Seen in cases of TB  h/o burning micturition: seen in UTI  h/o cough with sputum: respiratory infections  h/o diarrhoea,vomiting: gastroenteritis  h/o rash: typhoid, meningococcemia,SLE etc  h/o arthralgia: dengue, chikungunya

45. + A voice that is rough, harsh and lower in pitch than normal is usually described as hoarse + Its usually due to interference with the phonation function of larynx + Causes include  Inflammatory lesions of larynx:laryngitis, diphtheria, TB, syphilis  New growths:papiloma/fibroma/hemangioma  Paralysis of vocal cords:medullary damage (infarction,syringobulbia), RLN palsy ( following thyroid surgeries,aortic aneurysm,bronchial neoplasms)  Myasthenia gravis  Voice abuse

46. 1) OnsetAcute febrile onset in infectious laryngitis/diphtheria 2) DurationHoarseness associated with ARI is self limited and does not last more than 2-3 weeks 3) OccupationMore common in voice abusers like singers,teachers 4) PainTB of larynx causes pain localized to laryngeal area or referred to adjacent structures such as ear 5) h/o any trauma/thyroid surgery Suggests injury to RLN 6) Associated DypsnoeaBilateral PTB, mitral disease, aortic aneurysm,pericardial effusion 7) AphoniaAphonia but normal sound on coughing suggests Hysteria

47. + Sudden, involuntary, contraction of the diaphragm (usually unilateral) and other inspiratory muscles terminated by abrupt closure of the glottis + Occurs as a result of stimulation of one or more limbs of the hiccup reflex arc: – Involves irritation of the vagus and phrenic nerves(afferent) – The hiccup centre is located in the upper spinal cord – Efferents travel through phrenic nerve + Male-to-female ratio is 4:1: – In men, more than 90% of cases have an organic basis. – In women, a psychogenic cause is more likely

48. + Idiopathic + Gastrointestinal: – Gastric distention – Esophageal lesions – Reflux esophagitis/achalasia – Hepatic /pancreatic lesions – Appendicitis – Abdominal aortic aneurysm – Postoperative, abdominal procedure + Head and neck: – Otic foreign body irritating the tympanic membrane – Pharyngitis/laryngitis – Retropharyngeal/peritonsillar abscess + Diaphragmatic irritation: – Hiatal hernia – Tumors – Pericarditis – Eventration – Splenomegaly – Hepatomegaly – Peritonitis + CNS lesions: – Encephalitis – Subarachnoid hemorrhage/stroke – Arteriovenous malformations – Parkinson disease/multiple sclerosis + Mediastinal and other thoracic lesions: – Pneumonia – Aortic aneurysm – Tuberculosis – Myocardial infarction – Lung cancer + Metabolic causes: – Uremia/dm/gout – Hypocalcemia/natremia + Toxic/drug-induced: – barbiturates + Psychogenic causes: – Stress/excitement – Grief – Malingering – Conversion disorder

49.  PALPITATION  PEDAL EDEMA  WEIGHT LOSS  LOSS OF APPETITE  ABDOMINAL PAIN  URINARY AND BOWEL COMPLAINTS

50.  At the end of the history,a short summary outlining the salient or important facts of the case is prepared  The diagnostic impressions or tentative conclusions of the examiner are then added  This narrows down the subsequent field of exploration and cut out unnecessary examinations or investigations

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