Chest history taking


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Chest history taking

  1. 1. Ihr Logo Chest Case History Taking By Dr. Iman Hassan Lecturer of Pulmonary Medicine Ain Shams University E-mail:
  2. 2. Your Logo Page 2 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.
  3. 3. Your Logo Page 3 Importance of History Taking Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. It enables doctors to make accurate provisional diagnosis.
  4. 4. Your Logo Page 4 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.
  5. 5. Your Logo Page 5 Chest Case History Taking Personal history Complaint History of present illness  Cardinal chest symptoms  Minor chest symptoms Past history Family history
  6. 6. Your Logo Page 6 Personal History Name: 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
  7. 7. Your Logo Page 7 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
  8. 8. Your Logo Page 8 Chief Complaint The main reason that pushed the patient to seek for visiting a physician (or) for help. Patient own words Onset Course Duration
  9. 9. Your Logo Page 9 Complaint Onset:  Dramatic seconds  Sudden min/hrs  Rapid days  Gradual wks/months Course:  Progressive  Regressive  Intermittent  Stationary Acute
  10. 10. Your Logo Page 10 Complaint C/O: ……..+ Duration. C/O: …….+ Onset + Course + Duration. Short/specific in one clear sentence communicating present/major problem.
  11. 11. Your Logo Page 11 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.
  12. 12. Your Logo Page 12 History of Present Illness A. Cardinal Chest Symptoms: 1) Cough 2) Expectoration 3) Hemoptysis 4) Dyspnea 5) Chest Wheezes 6) Chest Pain 6
  13. 13. Your Logo Page 13 History of Present Illness B. Minor Chest Symptoms: 1) Toxemia 2) Mediastinal Compression 3) Respiratory Failure 4) Cor Pulmonale 5) Jaundice
  14. 14. Your Logo Page 14 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
  15. 15. Your Logo Page 15 2) Expectoration Amount Color: e.g., whitish, yellowish, reddish, greenish, rusty. Odour: odourless (or) foul odour Aspect: watery, mucoid, mucopurulent, purulent. Relation to posture
  16. 16. Your Logo Page 16 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.
  17. 17. Your Logo Page 17 3) Hemoptysis Type & Color: (frank, mixed or blood tinged) Amount Frequency Last attack Management / Blood transfusion
  18. 18. Your Logo Page 18 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.
  19. 19. Your Logo Page 19 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).
  20. 20. Your Logo Page 20 Causes of Hemoptysis
  21. 21. Your Logo Page 21 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
  22. 22. Your Logo Page 22 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
  23. 23. Your Logo Page 23 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
  24. 24. Your Logo Page 24 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
  25. 25. Your Logo Page 25 Grading of Dyspnea At Rest Exertional Grade Exertion Description Orthopnea 0 No No No dyspnea on walking upstairs Trepopnea 1 Mild Severe (3 flights) Dyspnea on walking upstairs Platypnea 2 Moderate Moderate (1-2 flights) dyspnea on walking for a distance of a mile Prayer’s position 3 Severe Minimal (100 yards) Dyspnea on walking 100 yards (from room to room) 4 V. Severe At Rest Dyspnea on dressing or undressing
  26. 26. Your Logo Page 26 Chest Causes of Acute Onset Dyspnea Pneumothorax Bronchial Asthma Pulmonary Embolism Foreign body
  27. 27. Your Logo Page 27 5) Chest Wheezes Definition: Musical sound produced by the passage of air through narrowed airways.
  28. 28. Your Logo Page 28 5) Chest Wheezes Timing of the attack Duration of the attack Frequency Course Associated symptoms Relief medications & Response
  29. 29. Your Logo Page 29 5) Chest Wheezes Causes Generalized Bronchial asthma Chronic bronchitis Cardiac asthma ABPA Localized Foreign body Endobronchial mass Viscid secretion Hilar LN enlargement
  30. 30. Your Logo Page 30 6) Chest Pain Onset 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
  31. 31. Your Logo Page 31 Causes of Chest Pain CardiacNon-Cardiac
  32. 32. Your Logo Page 32 Causes of Acute Chest Pain Coronary artery disease Pulmonary embolism/infarction Pneumothorax Pleurisy/ Pericarditis Dissecting aortic aneurysm Esophageal spasm
  33. 33. Your Logo Page 33 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
  34. 34. Your Logo Page 34 Brain Storming
  35. 35. Your Logo Page 35 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.
  36. 36. Your Logo Page 36 Case (1) Q. What is your provisional diagnosis? Q. What is the next investigation?
  37. 37. Your Logo Page 37 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.
  38. 38. Your Logo Page 38 Case (2) Q. What is your provisional diagnosis? Q. What is the next investigation?
  39. 39. Your Logo Page 39 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
  40. 40. Your Logo Page 40 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.
  41. 41. Your Logo Page 41 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.
  42. 42. Your Logo Page 42 Family History Similar familial chest condition. Other familial chest diseases.
  43. 43. Ihr Logo Questions
  44. 44. Ihr Logo