FOR 4TH YEAR BASICS IN HISTORY APPROACH

1. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
LONG CASE DISCUSSION: CASE NO: 1
30 year female Libyan is presented with bilateral leg swelling
of one week and progressive dyspnea for last day.
1. Chief complaint is the complaint which mandated the
patient presentation to the hospital whether it is a new
sever worry some symptom or chronic symptom with
sudden worsening.
C/O: leg swelling---one week
Dyspnea-------one day
2. History of present illness:
To reach the likely cause of the involved system symptoms.
The leg swelling started in the feet and ascends to the knees.
It wasn’t preceded by peri-orbital swelling and wasn’t
associated with joint swelling. It was gradual and progressive.
It is bilateral and involves both lower limbs. It is increased by
doing daily activity and on day time which was followed by
swelling of hands. It was associated with dyspnea.
The dyspnea was of gradual onset for last 4 months after the
delivery of healthy fetus. It is increased by exertion and mild
physical activity at home. It is relieved by rest. The dyspnea
wasn’t aggravated by exposure to dust, vapors and irritants. It
is associated with paroxysmal nocturnal dyspnea with
nocturnal dry cough and orthopnea. The dyspnea became
progressive for last day with dyspnea while talking even few
sentences and while history talking.
It wasn’t associated with fever, palpitation, chest pain and
wheezing.

2. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
Explanation:
The main symptoms should be analyzed to predict the likely
cause as it could explore the involved system.
The symptom should be analyzed regarding:
5 cardinal points:
Onset
Duration
Aggravating factors
Relieving factors
Associated symptom from the involved system.
Next step:
Review other systems that could cause the bilateral leg
swelling which are renal and liver symptoms.
The renal symptoms to be asked are:
 Bilateral loin pain
 Frequency of micturation
 Change of color of urine
 Change of amount of urine
 Hematuria
 Renal stones
 Polycystic kidney disease
She had decreased of frequency of urination but she didn’t
have any history of renal or urological problems before.
Chronic renal failure patients presents with symptoms of heart failure
due to retention of fluids and can be missed for month.

3. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
In DM and HTN, if the patient after ten years of diagnosis
showed uncontrolled DM/HTN or has multisystem complain, it
is mandatory to check renal function tests.
Remember, CRF is a laboratory diagnosis.
Regarding the liver, ask about:
a. Upper GIT bleeding—hematemsis
b. Lower GIT bleeding--- melena
c. Jaundice
d. Abdominal distention
e. Blood transfusion
f. Hepatitis
g. Right hypochondrial pain
She had a history of progressive abdominal distention for last
week with right hypochondrial fullness and loss of appetite.
Systemic review:
The systems which weren’t asked in the history should be
reviewed in quick manner.
Aim of review:
a. To correlate the presenting symptoms to other systems
to explore whether the patient had a local system
diseases or systemic disease with autoimmune bases.
b. To assess the severity of the illness as some infections
may involve other part of the body to indicate sepsis
c. To review all systems as the symptom may be secondary
to another illness in other system
d. The tumor may originate in one system and presents
with another symptom.

4. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
GIT----dysphagia, odynophagia, loss of appetite, loss of
weight, epigastric discomfort, right hypochondrial pain,
nausea, vomiting, diarrhea, constipation, jaundice,
hematemsis, melena, tensmus
CNS--- headache, diplopia, deafness, dysphagia, nasal speech,
dyspnea, dysarthria, dizziness, unsteadiness, parasthesia of
limbs, limb heaviness, tremors, abnormal movement, loss of
consciousness.
Locomotor--- joint pain or hotness and redness, which joints,
small joints or weight bearing joints, is it additive of
migratory, morning stiffness, loss of hair, skin rash. Types and
sites, erythema nodosum, Reynaud's phenomena
Pastmedical and past surgical history:
Ask about the chronic medical diseases ex, DM, HTN,
bronchial asthma, pulmonary tuberculosis and connective
tissues diseases.
The presentation could be a complication of previous
operation or a recurrence of previously treated problem in
another organ or same one.
Social history----the risk factor can be predicted such as
smoking, drug addict, heroin snuffer, sexual contact.
Poor income or high income can increase the incidence of
some illness
Family history----ask about DM, HTN, hypercholestremia,
allergy, connective tissue diseases, cardiomyopathy.
Many medical diseases have genetic implication which should
be recognized and identified as they are many.

5. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
Drug history---
a. Type of drug and dose
b. Duration of medication
c. Compliance
d. Is it accepted for his income
e. Follow-up regarding his illness
Aim:
a. To identify the underlying disease
b. To correlate the side effects of the medication if possible
c. To judge the appropriate drug and proper dose
d. Medications are toxins but we gave them aiming to take their
befits and avoid their side effects but they aren’t safe.
Summary:
New delivered female is presented with bilateral leg swelling
of a week and dyspnea of 4 months of progressive nature. She
had PND and orthopnea. She had no medical illness before
her presentation and no fever.
Questions:
1. What are the common symptoms of CRF?
1) Generalized itching
2) Dyspnea with clear chest due to acidosis( rate and depth )
3) Vomiting and hiccough
4) Chest pain piercing in nature
5) Parasthesia and numbness
a. Clinically earthy face, increased pigmentation, yellow skin
with clear sclera, scratch mark, uremic smell, acidotic
2. How to think about liver disease as cause of edema?
The commonest liver disease is liver cirrhosis.

6. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
The liver cirrhosis causes bilateral legs swelling in the
presence of portal hypertension which should be suspected:
a. Huge ascitis as compared to lower limbs swelling
b. Huge abdomen distention with thin body built
c. Portal HTN—esophageal varices with hematemsis, ascitis
with abdominal distention, splenomegally with left
hypochondrial discomfort.
Melena & hematemsis with ascitis point toward PHTN.
d. Huge abdomen with new grdual CNS confusion and
symptoms.
3. Enumerate the differential diagnosis of this lady?
a. Liver cirrhosis
b. Nephritic syndrome
c. Chronic renal failure
d. Congestive heart failure
4. What is the likely diagnosis from the history? explain
 The diagnosis is heart failure with congestion.
 The old term is congestive heart failure.
 The heart is made of left and right sides.
 The left ventricular failure is presented with inability of
the left ventricle to pump the blood for the appropriate
metabolism. This will lead to chest symptoms which may
be confused with lung diseases. She developed PND,
orthopnea and exertional dyspnea.
The symptoms are:
a. Progressive exertional dyspnea
b. PND and orthopnea
c. Cough from dry to productive
d. Positional cough and dyspnea
e. Watery frothy sputum
f. Wheezing
g. Hemoptysis
h. Chest tightness

7. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
i. Chest pain
j. Fatigue with syncopy
5. Is it enough to reach the diagnosis to be heart failure?
No, it is mandatory to know the cause for proper plan.
6. List some important questions to be asked to reach the
cause of heart failure?
i. Chest pain----- vascular heart disease
ii. Palpitation----- rhythm disturbance—atrial fibrillation
iii. Joint pain, tonsillitis in childhood—valvular heart disease
iv. Headache—occipital--- can be a clue toward HTN
v. Muscular--- can be expected in:
a. Young male with rapid heart failure after URTI
b. After excluding other causes, it is the likely one
especially in a patient with symptoms for years.
HOCM---MR and AS in young, H/O sudden death, familial
DCM---can be related to endocrine illness, alcohol intake, post
viral myocarditis, drug induced, electrolyte disturbance ,
postpartum
7. Could you predict the likely cause of her heart failure?
If a female develops heart failure while she is in 9th
month of
pregnancy OR after delivery, the cause of HF is postpartum CMP.
She had symptoms of LVF. PND, orthopnea, exertional dyspnea.
She had symptoms of RVF. Legs swelling, abdominal distention.
8. What are the signs of bi ventricular failure?
LVF--- chest on auscultation bilateral basal inspiratory fine crepts
LVF---CVS---may reveal gallop rhythm S3, PSM in MA
RVF--- bilateral pedal edema with raised jugular venous pressure
RVF--- hepatomegally with/without pulsation if there is TR.
CCF = HF = RVF + LVF = DYSPNEA + RAISED JVP
CCF SIGNS = S3 IN LVF + JVP RAISED IN RVF
LVF = pulmonary congestion, enter in D/D of all lung diseases.
RVF = systemic congestion, enter in D/D of causes of legs edema.

8. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
9. What are the causes of heart failure?
a. Vascular--- coronary artery—IHD,MI
b. Valvular---- left> right---RHD, IE
c. Rhythm----atrial fibrillation, ventricular tachycardia
d. Pressure-----HTN
e. Muscular -----acute myocarditis, Cardiomyopathy
f. Pericardial-----constrictive pericarditis
10. What is the cause of heart failure in diabetic?
DM and HTN are aggravating factors for atherosclerosis.
This will result in ischemic heart disease and infraction.
i. Big vessel-----coronary artery disease
ii. Small vessel----cardiomyopathy
11. What is the patho-physiology of CCF?
Two compensatory mechanisms are accused for the retention of fluid
in the negative spaces of the body.
 Sympathetic over-activity to increase heart rate, blood
pressure for better peripheral tissues perfusion and
increased myocardial contractility of the tired heart
 RAAS---rennin angiotensin aldosterone system activity
leading to the retention of the sodium with the water
retention which ended in dilution hyponatremia
This results in Na retention, fluid retention and vasoconstriction.
12.How to investigate this lady who has legs edema with clinical
suspicion of postpartum cardiomyopathy?
Some investigations are done to exclude other possibilities of
the legs edema and others are routine investigations.
Blood sugar, complete blood count, renal function test, liver
function test, urine for albumin, lipid profile.
The investigations to be done are ECG, cardiac enzymes, chest X
ray and ECHO.
The diagnostic test for CCF is atrial natriuretic peptide hormone.

9. HISTORY TAKING IN MEDICINE DR MAGDI AWAD SASI 2020
Coronary artery disease-------angiography
RHD-----ASO titer, DNAase, throat swab, dismutase
IE---------blood culture, trans-esophageal echo
Arrhythmia----holter24 monitoring, electro physiological study
How to treat a patient with heart failure?
The priority is to block the compensatory mechanism
which is RAAS as it has the upper hand in the retention
of the fluid.
a. ACE-I or ARB
b. Diuretic therapy
c. Atorvastatin tab
d. Aspirin tab 75mg
This part will be covered on the coming series of the
long case discussion session.