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Chest Case
History Taking
By
Dr. Iman Hassan
Lecturer of Pulmonary Medicine
Ain Shams University
E-mail: [email protected]
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Introduction
Aim of this lecture:
By the end of the session, doctors should know
fundamentals of chest history taking & become capable
of taking a chest history case.
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Importance of History Taking
Obtaining an accurate history is the criticalfirst step in determining the etiology of apatient's problem.
It enables doctors to make accurateprovisional diagnosis.
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General Approach Introduce yourself.
Note: never forget patient names
Treat patient appropriately in a friendly relaxed way.
Confidentiality & respect patient privacy.
Try to see things from patient point of view. Understand patient underneath mental status, anxiety, irritation or depression.
Always exhibit neutral position.
Listening.
Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions & summarizing.
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Chest Case History Taking
Personal history
Complaint
History of present illness
Cardinal chest symptoms
Minor chest symptoms
Past history
Family history
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Personal HistoryName: Familiarity & possible etiological diagnosis.
Age: Diseases common among certain age groups.
Sex: Diseases common related to the type of sex.
Race: Diseases common among certain races.
Occupation: Diseases common among certain occupations.
Residence: Diseases common among certain place of residency.
Marital status & off springs: Correlating certain diseases with fertility.
Habits of medical importance: e.g., smoking, addiction, bird breeding
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Personal History
Habits of medical importance:
• 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
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Chief Complaint
The main reason that pushed the patient toseek for visiting a physician (or) for help.
Patient own words
Onset
Course
Duration
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ComplaintOnset:
Dramatic seconds
Sudden min/hrs
Rapid days
Gradual wks/months
Course:
Progressive
Regressive
Intermittent
Stationary
Acute
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Complaint
C/O: ……..+ Duration.
C/O: …….+ Onset + Course + Duration.
Short/specific in one clear sentencecommunicating present/major problem.
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History of Present Illness
Objectives:
Elaborate on the chief complaint in detail.
Ask relevant associated symptoms.
Have differential diagnosis in mind.
Lead the conversation & thoughts.
Decide & weight the importance of minor complaints.
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History of Present Illness
A. Cardinal Chest Symptoms:
1) Cough
2) Expectoration
3) Hemoptysis
4) Dyspnea
5) Chest Wheezes
6) Chest Pain
6
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History of Present Illness
B. Minor Chest Symptoms:
1) Toxemia
2) Mediastinal Compression
3) Respiratory Failure
4) Cor Pulmonale
5) Jaundice
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1) Cough
Dry (or) Productive
Duration: Persistent, Short (or) Paroxysmal.
Timing: Nocturnal, Diurnal (or) All day.
Character: Suppressed, Brassy, Bovine, Croup (or) Barking
Site: Pharyngeal, Laryngeal, Tracheal, Bronchial, Pleural (or)
Parenchymal.
Complications: Vomiting, Syncope, Pneumothorax, Fracture rib
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2) Expectoration
Amount
Color: e.g., whitish, yellowish, reddish, greenish, rusty.
Odour: odourless (or) foul odour
Aspect: watery, mucoid, mucopurulent, purulent.
Relation to posture
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3) Hemoptysis
Hemoptysis is defined as coughing of blood
originating from below the vocal cords.
Life threatening (or) Massive hemoptysis is
defined as coughing of blood > 150 ml/time (or)
> 1000 ml/24 hours.
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3) Hemoptysis
Type & Color: (frank, mixed or blood tinged)
Amount
Frequency
Last attack
Management / Blood transfusion
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Causes of Hemoptysis
Pulmonary:
1. Tuberculosis.
2. Tumor.
3. Pneumonia.
4. Abscess.
5. Infarction.
6. Trauma.
7. Vasculitis & collagen disorders.
8. Cystic fibrosis.
9. Alveolar hemorrhage.
10.Arteriovenous malformation
Cardiovascular:
1. Left Ventricular Failure.
2. Mitral stenosis.
3. Aortic aneurism.
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Causes of Hemoptysis
Other causes:
1. Blood diseases.
2. Anticoagulant therapy.
Tracheobronchial:
1. Bronchitis (acute & chronic).
2. Bronchiectasis.
3. Foreign body.
4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors).
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Causes of Hemoptysis
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Differences between True Hemoptysis & Spurious (False) Hemoptysis
True hemoptysis False hemoptysis
Below vocal cords Above vocal cords
Persists as blood tinged sputum Does not persist
May be mixed with sputum Not mixed with sputum
History of cardiopulmonary disease Obvious by ENT examination
CXR may be abnormal Normal CXR
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Differences between Hemoptysis & Hematemsis
Hemoptysis Hematemsis
Coughing of blood Vomiting of blood
History of cardiopulmonary disease History of GIT disease
Bright red in color Dark brown in color
Sputum remains blood stained after the attack for few days
Usually followed by melena
Mixed with sputum Mixed with gastric contents
Blood is frothy Airless
Alkaline Acidic
Sputum contains hemosedrin laden macrophages
No
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4) Dyspnea
Onset
Course: grading of severity, ± orthopnea ± PND.
Duration
Frequency
Timing: Exertional (or) at rest.
Associated symptoms: e.g., chest pain, hemoptysis & wheezes.
Response to treatment
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Differences between Cardiac & Chest Dyspnea
Cardiac Bronchial
Age usually old usually young
History Cardiac disease Chest disease
Timing usually 2h after sleep usually in early morning
Duration Minutes Up to hours
Sputum Minimal pink frothy Viscid mucoid
O/E ± Valve lesion
Fine basal crepitations
± Wheezes
Wheezes
May be Silent chest
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Grading of Dyspnea
At RestExertional
Grade Exertion Description
Orthopnea 0 No No No dyspnea on walking upstairs
Trepopnea 1 MildSevere
(3 flights)Dyspnea on walking upstairs
Platypnea 2 ModerateModerate
(1-2 flights)
dyspnea on walking for a distance of a mile
Prayer’s position
3 SevereMinimal
(100 yards)
Dyspnea on walking 100 yards (from room to room)
4 V. Severe At Rest Dyspnea on dressing or undressing
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Chest Causes of Acute Onset Dyspnea
Pneumothorax
Bronchial Asthma
Pulmonary Embolism
Foreign body
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5) Chest Wheezes
Definition:
Musical sound produced by the passage
of air through narrowed airways.
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5) Chest Wheezes
Timing of the attack
Duration of the attack
Frequency
Course
Associated symptoms
Relief medications & Response
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5) Chest WheezesCauses
Generalized
Bronchial asthma
Chronic bronchitis
Cardiac asthma
ABPA
Localized
Foreign body
Endobronchial mass
Viscid secretion
Hilar LN enlargement
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6) Chest PainOnset
Course
Duration
Character: stitching, stabbing, sawing (or) burning.
Site
Radiation (or) Referral
What ↑ & what ↓
Severity: Interfering with daily activity (or) sleep rhythm.
Associated symptom
History of trauma (or) surgery
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Causes of Chest Pain
CardiacNon-Cardiac
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Causes of Acute Chest Pain
Coronary artery disease
Pulmonary embolism/infarction
Pneumothorax
Pleurisy/ Pericarditis
Dissecting aortic aneurysm
Esophageal spasm
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Minor Chest Symptoms
1) Chronic Toxemia: night sweating & fever, loss of weight & appetite.
2) Mediastinal Compression: Dysphagia, hoarseness, brassy cough, edema
of eye lid (or) neck swelling.
3) Respiratory Failure: ✪ Hypoxia: (agitation, cyanosis, fine tremors).
✪ Hypercapnic: (inverted sleep rhythm, drowsy,
headache, flapping tremors).
4) Cor Pulmonale: Bilateral LL swelling, Rt hypochondrial pain, dyspepsia.
5) Jaundice
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Brain Storming
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Case (1)
60 years old male smoker presented to the ER with coughing of
about 100 cc of bright red blood, he gave history of blood tinged
sputum 10 days ago lasting for 2 days.
The patient gives history of weight loss of about 20 Kg in the past
3 months with repeated attacks of right sided sawing chest pain
not relieved by analgesics with no radiation or referral.
O/E: vitally stable ENT & Heart NAD
Chest exam.:↓ intensity over right mammary area.
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Case (1)
Q. What is your provisional diagnosis?
Q. What is the next investigation?
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Case (2)
45 years old male non-smoker presented to the ER with coughing
of about 1/4 cc of blood tinged sputum, along with night
sweating & fever, subjective loss of weight & appetite of 1 month
duration.
The patient gives history being in prison for the past 6 months, &
was released from jail 2 months ago.
O/E: temperature 39 C°.
Chest exam.:bronchial breathing over the left hemithorax with
bilateral scattered coarse non-fixed crepitations.
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Case (2)
Q. What is your provisional diagnosis?
Q. What is the next investigation?
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HPI: Clinco-Pathological Approach:
Bronchial disease: cough, expectoration, wheezes
Dyspnoea Hemoptysis
Parenchymatous disease: constitutional
Pleural disease: pleuritic chest pain, dry cough
Complicated chest disease: RF/ Cor pulmonale
Provisional Diagnosis
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Past History
Why do we ask for past history?
To determine the etiology of illness.
To avoid giving any future medications that will worsen the condition.
To determine any medical co morbidities or medications that might predispose to illness.
To assess for treatment modalities that might contraindicate with the current condition of the patient.
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Past History(Medical & Surgical)
Similar chest condition.
Tuberculosis (or) Anti TB treatment.
Bilharziasis.
Previous hospitalization.
Previous surgery.
Blood transfusion.
Drug allergy.
Co-morbid condition: DM, HTN, Renal or hepatic disease.
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Family History
Similar familial chest condition.
Other familial chest diseases.
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Questions
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