1. Basic principles of a history
"Listen to the patient. He is telling you the diagnosis,"
comes the wisdom of ages.
•To do this efficiently questions should be open-ended and allow
for patients to speak freely.
•Be selective with direct questioning. The patient may gloss over
something that demands deeper inquiry.
•Try not to interrupt unnecessarily (but there are times when it is
essential to hone in on detail).
•Avoid irrelevant detail. Some patients can meander aimlessly
with irrelevant anecdotes and these need to be gently curtailed.
•Avoid leading questions.
•Let the patient speak freely in his own words.
NAME
AGE
SEX
OCCUPATION
History of presenting complaint
The main complain which bring him to hospital.
There will be a lot of complain which is the main and recent.
Enumerate the main complains as a list one by one.
MAGDI AWAD SASI 2013

2. Following the principles above ask:
•What is the principle complaint? Examples include dyspnoea,
wheezing or cough as below.
•Are there subsidiary complaints?
•What is the time scale of the complaint?
•Is the disease progressive or static?
•Is the problem constant or paroxysmal? If it is variable, are the
good times symptom free or less severe?
•Are there any aggravating or relieving factors?
•How severely does it affect the patient's life?
5 questions are mandatory to be asked:
1.
2.
3.
4.
5.
ONSET
DURATION
AGGREVATING FACTORS
RELEAVING FACTORS
ASSOCIATED SYMPTOMS- other symptoms from the
same system of the related complain
IF THE PATIENT PRESENTED WITH PAIN , ADD 5 QS:
6. SITE
7. CHARACTER/ TYPE
8. REDIATION
9. SEVERITY
10. COURSE
MAGDI AWAD SASI 2013

3. FOR EXAMPLE, Dyspnoea and wheeze
The questions may apply to both dyspnoea and wheezing
•When do symptoms occur?
•Is there shortness of breath on exertion? How much exertion?
•Is it getting worse?
•Do symptoms occur at rest?
•Does anything else precipitate it? This can include cold air,
pollution and lying flat.
•What does the patient do when it happens? He may stop for
breath, he may seek fresh air, he may sit up.
•Are there any undue problems with a cold? Asthma and COPD
are often aggravated by a cold.
What is the importants of asking about other systems?
Remember that respiratory symptoms may be caused by
disease of other systems:
•Congestive heart failure may cause dyspnoea at night.
The patient sits up and throws open the windows.
•Severe anaemia causes shortness of breath on exertion.
•Neuromuscular disease can cause dyspnoea.
•Dyspnoea can be psychogenic (with features of the
hyperventilation syndrome).
•Only moderate asthmatics wheeze. In severe asthma
there may be no wheeze and a silent chest.
•It is important to distinguish wheeze from stridor.
MAGDI AWAD SASI 2013

4. 2ND EXAMPLE, Cough
Questions to ask about cough include:
•Does anything bring it on? Think of the same
precipitants as asthma.
•When does it tend to happen? A nocturnal cough could
be heart failure, a postnasal drip or gastro-oesophageal
reflux.
•Is it dry or productive? "Do you bring anything up?" is
the question to ask the patient.
•If the cough is productive, what colour is the sputum?
Green or yellow suggests infection.
•"Do you ever cough up blood?" You should have a
mental differential diagnosis for haemoptysis.
Remember that mild asthma can present with cough.
Paroxysmal nocturnal coughing can be from heart failure.
ACE inhibitors may cause cough.
3rd EXAMPLE Chest Pain
Where is the pain (l)?
When did the pain first start (t)?
How long does it last (t)?
Does the pain radiate, if so where (q2/am)?
How often do you have the pain (q2)?
How would you describe the pain - burning, pressing, stabbing,
crushing, dull, aching, throbbing, sharp, constricting (q1)?
MAGDI AWAD SASI 2013

5. Does the pain occur at rest, with exertion, with stress, after
eating, when moving your arms, or during intercourse (af/s)?
Do you have any other symptoms with the pain such as
shortness of breath, palpitations, nausea, vomiting, coughing,
fever, leg pain (as)?
4TH EXAMPLE Edema (dependent)
Do you have swelling in your legs?
When did you first notice the swelling?
Did it appear suddenly or gradually?
Is the swelling worse in the morning or evening?
Does the swelling decrease after a night's sleep?
Do you shortness of breath associated with the swelling?
Have you noticed any change in your weight?
Does elevating your feel make the swelling go down?
Do you have pain in your legs associated with the swelling?
Do both legs swell equally?
Are you taking any medications, if so, which ones?
THREE QUESTIONS NOT TO BE MISSED IN CHIEF COMPLAIN:
1. FEVER
2. LOSE OF APETITE
3. LOSE OF WIEGHT
Presence of the fever gives a clue that the likely cause is infection,
although fever can be caused by connective tissue diseases or
hematological malignancy or occult tumours.
The three symptoms of one month is likely to be tuberculosis or
occult abscess in the inquired system.
MAGDI AWAD SASI 2013

6. Review the systems which was not mentioned in history
CVS:
Dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cough,
sputum , chest pain , wheeze, haemoptysis , palpitation, Pain in the
calves, buttocks or thighs when walking more than a certain distance
(claudication) , Tiredness (fatigue) ,Preceding sore throat, joint
pain/swelling, chorea, rash , Ankle swelling
Respiratory:
cough , dyspnea , sputum , wheezing , chest pain, chest tightness ,
haemoptysis
CNS :
Headache , diplopia , lose of vision, deafness ,dysphagia ,
dysarthria, dyspnae , dysphonia , dizziness , dysphasia, weakness of
limbs , Unsteadiness , tremors , deviation of angle of mouth , lose of
consciouscness , vomiting , sweating , parasthesia and numbness of
limbs , memory disturbance , aphasia
Locomotor:
joint pain , large or small, at once or migratory , arthralgia or
arthritis , skin rash , lose of hair , muscle pain , haematuria , back
pain, neck pain , on / off symptoms
MAGDI AWAD SASI 2013

7. Genitourinary:
frequency , amount , nocturia ,polyuria, loin pain , haematuria ,
incontinence , decrease or increase in amount
Gastrointestinal :
Lose of apetite ,Dysphagia ,dyspepsia , epigastric pain , right
hypochondrial pain , change of bowel habit , constipation , diarrhea ,
haematemesis ,bleeding per rectum , painful defecation
Endocrine:
Appetite and weight ,neck swelling, muscle weakness , memory
disturbance , emotional liability ,sleeplessness , personality changes ,
palpitation, sweating , lose of libido , failure of lactation in female,
lose of hair growth around face in male and axilla in female ,
pigmentation change increased or decreased , change of menstrual
cycle , new onset of diabetes or hypertension , headache.
MULTISYSTEM COMPLAIN CAN BE
Renal failure in DIABETICS
, Connective tissues disease in young female ,
or Endocrine disease.
MAGDI AWAD SASI 2013

8. IN SUMMARY, KEEP IN YOUR MIND THAT THIS
SYSTEMATIC INQUIRY IS HELPFUL FOR DIAGNOSIS.
It is important to ask about other body systems. There
may be undiagnosed illnesses in other systems which are
relevant to the respiratory symptoms.
•Loss of appetite is a common feature whenever people
are unwell. It suggests that the disease is having a
significant effect on wellbeing.
•Significant loss of weight may well be indicative of
serious illness. Remember malignancy and tuberculosis.
•Ask about urinary symptoms. Middle-aged and older
women, in particular, may be less concerned about the
cough than the associated stress incontinence. Ask about
it as they are often too embarrassed to complain directly.
•Heart disease may cause respiratory symptoms. Are
there for example symptoms of heart failure, angina or
ankle swelling?
•Rheumatoid arthritis and other connective tissue
diseases may cause respiratory symptoms.
MAGDI AWAD SASI 2013

9. •Neuromuscular diseases may cause respiratory
symptoms, particularly dyspnoea.
PAST MEDICAL AND SURGICAL HISTORY
Previous diagnosis and treatment
Between the history of the presenting complaint and past medical
history, it is worth asking if there has been any previous
consultation about the problem, a previous diagnosis and any
previous treatment?
This may seem a little like cheating in finals but in real life it is
very important. Has there been previous investigation and a
diagnosis?
It may be right or it may be wrong but it is important to know
about it. Has there been any previous attempt at treatment? If so,
with what and how successful was it?
Blessed is he who sees the patient last.
MI, angina.
Rheumatic fever.
HTN, HTN of pregnancy.
Congenital heart problems.
STDs, infections.
Dental work (S. viridans).
Investigations: angiogram.
Surgery: CABG, transplant, valve replacement, angioplasty.
MAGDI AWAD SASI 2013

10. It is often the past history that gives the clue to the
aetiology. Ask about:
•Childhood asthma, wheezing or 'bronchitis'.
•Malignant disease (pulmonary metastases). Remember
busulphan can cause pulmonary fibrosis.
•Infections including pneumonia, tuberculosis and
whooping cough.
•Chest trauma and operations.
•Thromboembolic disease, specifically deep vein
thromboses and pulmonary embolus.
Allergies
Ask about all allergies including for example food,
inhaled allergens and drugs.
Drug history
Specifically:
•Use of inhalers (assess compliance and technique).
•Use of steroids (some measure of severity in asthma).
•Other drugs which may have relevance in respiratory disease
(such as busulphan, ACE inhibitors, aspirin, NSAIDs).
MAGDI AWAD SASI 2013

11. Family history
Diseases can have a genetic component or aetiology such as
asthma and cystic fibrosis. Ask also about:
•Infectious diseases such as tuberculosis (remember high risk
groups).
•Atopic diseases such as hay fever and eczema.
•Emphysema (alpha-1-antitrypsin deficiency
Condition in a relative, what age.
MI.
Angina.
Congenital heart dz.
Mitral valve prolapse.
Marfan's.
DM.
HTN.
Social history
•An occupational history may be very important in
respiratory disease. This is highlighted with
conditions such as asbestosis where there may
have been exposure in the building industry for
example.
It is important to ask about past occupations too.
Remember an electrician, a carpenter and a sailor
in the merchant navy may all have been exposed to
asbestos
•Hobbies and pets may also be responsible for
respiratory disease.
MAGDI AWAD SASI 2013

12. •Lifestyle and alcohol consumption are also very
relevant to respiratory diseases. Ask about illicit
drugs. They may be smoked or inhaled.
•Smoking history should detail for example the
type and number of cigarettes smoked currently
and in the past.
Remember that some children start to smoke very
early in life.
Ask about passive smoking.
•Sexual history may be relevant to risk of HIV and
AIDS.
Smoking: ever smoked, how many per day, for how
long, type [cigarette, pipe, chew].
Alcohol (hypercholesteremia risk).
Occupation: stress, work interruption.
Activity levels.
High cholesterol diet.
Describe your home: stairs, etc.
Who is with you there at home [help if MI, help with
tasks].
Wash hands, Introduce self, Gain consent
Ask Name & Age
OH (Occupational History)
PC (Presenting Complaint)
HPC (History Presenting Complaint)
Chest Discomfort
Onset ,Character, Location, Duration, Radiation, Severity, Precipitant or
relieving factors.
Had it i/n the past? Are there other pain symptoms?
MAGDI AWAD SASI 2013

13. Dyspnoea
What is the likely origin – heart or lungs?
Is there a wheeze? Is it exertional? If chronic – do they have their
normal peak flow?
Is breathlessness worse lying down? Is it worse at night?
Precipitating/relieving factors (how many pillows do you use?)
Is the breathlessness with or without pain
How far can the patient mobilise compared to pre symptoms? (NYHA)
Palpitations (awareness of heart beating, or skipping)
Most causes are non cardiac. What do they mean to the patient. What is
the duration and
what brings them on?
Syncope (dizziness)
Many causes. Could be neurological, bradycardia or arrhythmias. What
brings it on? Postural
cause is unlikely to be cardiac
Intermittent Claudication or cramping in the legs? Calf swelling?
You would also include screening questions for peripheral vascular
history/
PMH (e.g. Ops, Heart problems, lung problems, Ca, High BP, diabetes,
thyroid, rh. Fever)
DH (Drug History) & Allergies
Any over the counter drugs or specific prescription medication?
Recreational drugs?
RF (Risk Factors)
Smoking ,Alcohol, Cholesterol, Diet and exercise
FH (Family History)
e.g. Heart disease, lung problems, high BP, CA
SH (Social History)
Who is at home? Finances, Type of house etc. (2 floors?)
How does this affect home life?
Ideas, Concerns & Expectations
.
MAGDI AWAD SASI 2013