Chest case history taking :Chest case history taking


Basic components of the history :Basic components of the history Chief complain History of presence illness Past history Family history Social history Review of systems


Chest case history taking :Chest case history taking Personal history Complaint History of present illness Cardinal chest symptoms Minor chest symptoms Past history Family history


Chest case history taking :Chest case history taking Personal history Name Age Sex Race Occupation Residence Marital status & children Habits


Personal history :Personal history Name ? Familiarity Age Young age ? Cystic fibrosis, Asthma, TB Middle age ? Infections, Asthma Old age ? COPD, Bronchogenic carcinoma, Pulmonary embolism Sex Male ? COPD, Bronchogenic carcinoma, Occupational diseases Female ? Pulmonary embolism, 1ry P++, Bronchial adenoma Race ? TB > Negroes


Personal history :Personal history 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, TB Endemic areas/ rural ? B, Hydatid, Filariasis.


Personal history :Personal history Marital status & children Female: Deliveries/abortions/contraceptive pills /TB salpingitis + menstrual history Male: TB epididymitis/ S / CF Habits Smoking / X-smoker Pack years = Number of cigarettes/day ? Years 20 Alcohol ? Aspiration, Lung abscess, Hypoventilation Drug addiction ? Resp. depression, Septic embolism Bird breeder ? EAA


Social & environmental history :Social & environmental history


Social & environmental history :Social & environmental history


Chest case history taking :Chest case history taking Complaint Try to define the main C/O and its duration. What C/O have brought you to the clinic today? What sort of problems have you been experiencing? Next Question? Would you tell me more about it?


Chest case history taking :Chest case history taking Complaint Patient own words????? Onset Course Duration


Complaint (C/O) :Complaint (C/O) Patient own words / most distressing Onset: Dramatic seconds Sudden min/hrs Rapid days Gradual wks/months Course Progressive Regressive Intermittent Stationary Acute


Complaint (C/O) :Complaint (C/O) Duration Short Long C/O:……..+ duration. C/O:…….+ onset + course + duration.


History of present illness :History of present illness Tell your story from begging without interruption. Counsel of perfection Enlarge on any point needed


Chest case history taking :Chest case history taking History of present illness Cardinal chest symptoms Cough Expectoration Haemoptysis Dyspnoea Asthmatic attacks & Wheezing of chest Chest pain Minor chest symptoms


Chest case history taking :Chest case history taking History of present illness Minor chest symptoms Toxemia Mediastinal compression Respiratory failure Corpulmonale Jaundice Cyanosis


History of present illness :History of present illness Analysis of C/O: onset, course & duration Cardinal chest symptoms 6 Cough Expectoration Haemoptysis Dyspnoea Asthmatic attacks & Wheezing of chest Chest pain


Cough :Cough Dry or productive Dry ? URTI, irritant inhalation Productive ? Abscess, chronic bronchitis, pneumonia Time ? Morning/ Night/ No relation Short or paroxysmal Short ? URTI, Pleurisy Paroxysmal ? FB, asthma Character e.g. Brassy - Bovine Suppressed - Crup Complications……..


Cough :Cough Types of cough: Pharyngeal ? Pharyngitis, Post nasal discharge Laryngeal ? Laryngitis Tracheal ? Tracheaitis Bronchial ? Acute bronchitis, COPD, Asthma, Bronchiectasis, Bronchogenic carcinoma Parenchymal ? Pneumonia, APO, Fibrosis Others ? Drugs, GERD


Expectoration :Expectoration Amount ? Large Color Whitish ? bronchitis, asthma, APO Yellowish ? LRTI, Supprative lung disease Greenish ? Retained pus Rusty ? pneumonia Chocolate ? Amoebic abscess Red current jelly ? Freidlander pneumonia, BC Odor


Expectoration :Expectoration Relation to posture Related ? Localized bronchial disease Not related ? Generalized bronchial disease Aspect Serous Viscid Mucoid Mucopurulent/ purulent


Haemoptysis :Haemoptysis Type & color (frank, mixed or blood tinged) Amount Frequency Last attack Management / Blood transfusion


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


Haemoptysis :Haemoptysis Massive 200 to 600 ml/24h Life threatening 150 ml Causes: TB, Bronchiectasis, Mycetoma, Bronchogenic carcinoma, Lung abscess, Necrotizing pneumonia & vascular anomalies False or true: Above or Below vocal cords


Haemoptysis :Haemoptysis


Haemoptysis :Haemoptysis Causes of Haemoptysis in TB: Granulomatous ulceration of bronchial mucosa Rupture of unsupported vessel in TB cavity Calcified node eroding into pulmonary or bronchial artery.


Case 2- Haemoptysis :Case 2- Haemoptysis A 35 year old female never smoked presented to ER C/O coughing of frank blood. It was bright red, about ¼ cup in amount. She gave history of blood tinged sputum 1 week ago lasting for 2 days duration, were it was relived by anti-tussives. No other C/O. O/E: vitally stable ENT & Heart ? NAD Diminished intensity over left infrascapular area. CXR: Left lower lobe collapse. Next investigation? Provisional diagnosis?


Dyspnoea :Dyspnoea How short of breath is the patient? Grade When does it comes? Exertional/ Rest Does it comes in attack? Paroxysmal Does he have attacks of breathlessness at night? Does he have to sit up or can he sleep lying down? Orthopnea


Dyspnoea :Dyspnoea Exertional Mild, moderate or severe. Paroxysmal Cardiac / bronchial asthma Others?(e.g. Carcinoid, Uremic asthma) Orthopnea (advanced CHF, COPD or asthma- massive ascites, late months of pregnancy) At rest


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Dyspnoea :Dyspnoea Acute onset Dyspnoea Pneumothorax Asthma Pulmonary embolism APO FB


Slide 36:Dyspnoea of slow onset Wheeze Wheeze No Atopic? Asthma ± Sputum Smoker COPD Sputum++ Bronchiectasis Occupational history Pneumoconiosis ± Crackles ++ Interstitial lung disease ± Pleurisy ± Haemoptysis Pulmonary embolism


Asthmatic attacks & Wheezing of chest :Asthmatic attacks & Wheezing of chest How long is the attack? Total duration Time? Duration? Individual wheezing attack Frequency? Severity ? PPt/ relief/ response to usual medication? Condition between attacks? Hospitalization? Progression of symptoms overtime? Associated symptoms?


Wheezing of chest :Wheezing of chest Obstructive diseases e.g upper airway obstruction Restrictive diseases e.g. PO, EAA, Eosinophilia Pulmonary vascular diseases Tumors of lung Infectious lung diseases Miscellaneous e.g. FB, drug-induced, Carcinoid


Case 3-Wheezing of chest :Case 3-Wheezing of chest A 10 year old boy who had asthma for several years was brought to the Outpatient clinic with wheezing all night with unable to sleep following football match. His parents were concerned when they noted bluish coloration of lips and his vigorous use of the neck muscles. He took his usual medication with additional doses of his inhaler with no improvement. What is the next step should the doctor do? Home treatment. ER treatment Admission to RICU Admission to ward


Chest pain :Chest pain Onset, course & duration Site Character Severity Radiating or referred What ? & what ? Association


Chest pain :Chest pain Pulmonary: Pulm. Embolism, pleurisy, pneumothorax, P++ Cardiac: Angina, Myocardial infarction, MVP, Pericarditis, Dissecting aortic aneurysm, GI: Spasm, Reflux Chest wall: Vertebral column


Chest pain :Chest pain Chest wall pain: Trauma (recent or healed # rib) Tietze `s syndrome Herpes zoster Osteoporosis Intrathoracic structures Tracheitis, bronchitis Esophageal pain, Pericarditis, Myocardial disease, Dissecting aortic aneurysm Mediastinal (Tumors, LNs) Breast tenderness


Chest pain :Chest pain Pleuritic chest pain DD Acute onset chest pain CAD Pulmonary embolism/infarction Pneumothorax Pleurisy/ Pericarditis Dissecting aortic aneurysm Esophageal spasm


Chest pain :Chest pain Intensify with breathing ? Pleuritic Local tenderness ? skin, SC tissue, fat, breast, or bone. Rertosternal + coughing or breathing ? Tracheitis. Rertosternal without coughing ? Cardiac, mediastinal or esophageal origin


Case 4- Chest pain :Case 4- Chest pain A 67 year old male developed an attack of right inframammary chest pain 1 week after an orthopedic operation following car accident.The pain occurred suddenly, for few seconds & relived spontaneously without medication. No associated C/O. Provisional diagnosis based on history ?


Minor chest symptoms :Minor chest symptoms Chronic toxemia Corpulmonale (DD of LL edema in chest case) Mediastinal compression Dysphagia, hoarseness, brassy cough, edema of eye lid or neck swelling Respiratory failure Hypoxic: Irritability, cyanosis, lack of concentration, tachycardia, fine tremors. Hypercapnic: Disturbance of sleep rhythm, headache, flappy tremors, drowsiness .


Minor chest symptoms :Minor chest symptoms Cyanosis Jaundice? DD of jaundice in chest case


Other symptoms :Other symptoms Drug intake all / dose/ duration / side effects DM Hypertension Other systems affection


HPI: Clinco-pathological approach :HPI: Clinco-pathological approach Bronchial disease cough, expectoration, wheezes Dyspnoea haemoptysis Parenchymatous disease constitutional Pleural disease pleuritic chest pain, dry cough Complicated chest disease Resp. failure/ corpulmonale Provisional diagnosis


Past history :Past history Similar conditions/ previous resp. illness Hospitalization/ sanatorial admission TB B Operations/ blood transfusion ? trauma, allergic conditions, FB inhalation…………


Past history clues :Past history clues


Family history :Family history Similar diseases in the family Important diseases in the family Chest diseases in family Age, health or cause of death of parents


Chest case history taking :Chest case history taking Personal history Complaint History of present illness Cardinal chest symptoms Minor chest symptoms Past history Family history


Thank you :Thank you