History taking

clinical approach to a patient with chest pain

1. CLINICAL APPROACH CLINICAL APPROACH
TO A PATIENT WITH TO A PATIENT WITH
COUGH… HISTORY COUGH… HISTORY
TAKINGTAKING

2. ►Protective mechanismProtective mechanism
►Seeks MEDICAL CARESeeks MEDICAL CARE
Discomfort from cough itselfDiscomfort from cough itself
Interference with normal lifestyleInterference with normal lifestyle
Concern for cause of coughConcern for cause of cough

3. HISTORYHISTORY
1.Onset & Duration1.Onset & Duration
Acute :- URTI; pneumonia; Acute :- URTI; pneumonia;
aspiration; foreign body; aspiration; foreign body;

pulmonary emboli; CHFpulmonary emboli; CHF
Chronic :-COPD; bronchogenic CA; Chronic :-COPD; bronchogenic CA;
post nasal drip; asthma; post nasal drip; asthma;
GERD; TB; ILD; GERD; TB; ILD;
psychogenicpsychogenic

4. 2.Character and timing2.Character and timing
Short,dry irritating cough with Short,dry irritating cough with
pain behind jaw or neck:- pain behind jaw or neck:-
PharyngealPharyngeal
Harsh,irritative and repetitive Harsh,irritative and repetitive
with stridor and cyanosis:- with stridor and cyanosis:-
LaryngealLaryngeal

5. Productive: amount; colour; Productive: amount; colour;
consistency; smellconsistency; smell
Large amounts:-Large amounts:-
a)regular coughing up-bronchiectasis a)regular coughing up-bronchiectasis
b)Single occasion-lung abcess, b)Single occasion-lung abcess,
empyemaempyema
c)Pink frothy-Pulm edemac)Pink frothy-Pulm edema

6. Types of sputumTypes of sputum
TypesTypes AppearanceAppearance CauseCause
SerousSerous Clear,watery Clear,watery
frothy pinkfrothy pink
A/c pulm A/c pulm
edemaedema
MucoidMucoid Clear grey- Clear grey-
white viscidwhite viscid
C/c bronchitis, C/c bronchitis,
COPD,AsthmaCOPD,Asthma
PurulentPurulent Yellow/greenYellow/green BronchopulmonaBronchopulmona
ry infectionry infection
RustyRusty Rusty,golden Rusty,golden
yellowyellow
Pneumococcal Pneumococcal
pneumoniapneumonia

7. FROTHY SPUTUMFROTHY SPUTUM

8. PURULENT SPUTUMPURULENT SPUTUM

9. RUSTY SPUTUMRUSTY SPUTUM

10. Foul smelling sputum- bronchiectasis, Foul smelling sputum- bronchiectasis,
lung abcess, empyemalung abcess, empyema
Solid matter present in viscid Solid matter present in viscid
secretions in asthma, allergic secretions in asthma, allergic
brochopulmonary aspergillosis, brochopulmonary aspergillosis,
necrotic tumour, foreign bodynecrotic tumour, foreign body

11. Haemoptysis;- C/c bronchitis, Haemoptysis;- C/c bronchitis,
Bronchiectasis, Bronchogenic Bronchiectasis, Bronchogenic
carcinoma, Pulmonary emboli, carcinoma, Pulmonary emboli,
Pulmonary edemaPulmonary edema

12. 3.Diurnal variation3.Diurnal variation
Cough which gets worse in night and Cough which gets worse in night and
early morning :- Asthmaearly morning :- Asthma
Persistent moist cough on waking up Persistent moist cough on waking up
in smokers :- C/c bronchitisin smokers :- C/c bronchitis

13. 4.Seasonal variation4.Seasonal variation
Asthma, C/c bronchitisAsthma, C/c bronchitis
5.Postural variation5.Postural variation
Bronchiectasis, Lung abcess, Bronchiectasis, Lung abcess,

14. 6.Aggravating & Relieving factors6.Aggravating & Relieving factors
Cold,smoke,dust,exertion:- Cold,smoke,dust,exertion:-
asthma asthma
Swallowing of liquids:- NM d/s Swallowing of liquids:- NM d/s
of oropharynxof oropharynx

Otogenic cough:- impacted wax or Otogenic cough:- impacted wax or
foreign body in ext auditory meatus:foreign body in ext auditory meatus:
…..subsides with removal of cause …..subsides with removal of cause

15. 7.Associated symptoms7.Associated symptoms
Fever:- RTI; lung abcess; Fever:- RTI; lung abcess;
Chest pain:-Bronchitis, Chest pain:-Bronchitis,
bronchogenic carcinomabronchogenic carcinoma
Pleuritic chest pain:-Pleurisy, Pleuritic chest pain:-Pleurisy,
pleural effusion,bronchiectasispleural effusion,bronchiectasis

16. Dyspnoea:- COPD, Asthma, ILD, Dyspnoea:- COPD, Asthma, ILD,
Pneumonia, Bronchogenic carcinoma, Pneumonia, Bronchogenic carcinoma,
Sarcoidosis, CHF ( orthopnoea & Sarcoidosis, CHF ( orthopnoea &
PND)PND)
Wheeze:- asthmaWheeze:- asthma
“ “cough variant asthma”cough variant asthma”
Nasal discharge, tickling sensation in Nasal discharge, tickling sensation in
throat:- Postnasal dripthroat:- Postnasal drip

17. Loss of weight:- bronchogenic Loss of weight:- bronchogenic
carcinomacarcinoma
Stridor:-FB,Laryngeal nerve Stridor:-FB,Laryngeal nerve
involvmentinvolvment
Hoarseness of voice:-Lary.N invlvmtHoarseness of voice:-Lary.N invlvmt
Heart burn, regurgitation:- GERDHeart burn, regurgitation:- GERD
Erythema nodosum:-SarcoidosisErythema nodosum:-Sarcoidosis

18. HISTORY OF PAST ILLNESS
COPD, Asthma, Postnasal drip, GERDCOPD, Asthma, Postnasal drip, GERD
R/c or complicated Pneumonia, R/c or complicated Pneumonia,
tuberculosis.whooping cough:- tuberculosis.whooping cough:-
BronchiectasisBronchiectasis
ImmunosuppressionImmunosuppression
Surgery ;bed restSurgery ;bed rest
BCG vaccinationBCG vaccination

19. Personal historyPersonal history
Loss of appetite, sleepLoss of appetite, sleep
SmokingSmoking
Occupational exposureOccupational exposure
Allergy or atopyAllergy or atopy

20. FAMILY HISTORYFAMILY HISTORY
Chronic bronchitis with emphysema, Chronic bronchitis with emphysema,
Respiratory allergy, Asthma, Cystic Respiratory allergy, Asthma, Cystic
fibrosisfibrosis
TBTB

21. TREATMENT HISTORYTREATMENT HISTORY
Angiotensin Converting Angiotensin Converting
Enzyme InhibitorsEnzyme Inhibitors
Past treatment of d/s like Past treatment of d/s like
allergies,asthma,pneumonia,TB,Bronallergies,asthma,pneumonia,TB,Bron
chitischitis
ImmunosuppressantsImmunosuppressants

22. ……DDsDDs
1.Pneumonia:-fever, cough,dyspnoea, 1.Pneumonia:-fever, cough,dyspnoea,
rigor,night sweatsrigor,night sweats
2.Asthma:-episodic wheeze,dyspnea, c/c 2.Asthma:-episodic wheeze,dyspnea, c/c
dry or productive cough worst at dry or productive cough worst at
night,chest tightnessnight,chest tightness
3.COPD:-persistent cough,large amount 3.COPD:-persistent cough,large amount
sputum,shortness of breathsputum,shortness of breath

23. 4.Bronchiectasis:-c/c cough,copious 4.Bronchiectasis:-c/c cough,copious
amount of foul smelling sputum, amount of foul smelling sputum,
hemoptysis,pleuritic chest pain, hemoptysis,pleuritic chest pain,
dyspnoea,loss of weight,anemiadyspnoea,loss of weight,anemia
5.Bronchogenic carcinoma:-new 5.Bronchogenic carcinoma:-new
cough/change in cough,dyspnoea, cough/change in cough,dyspnoea,
hemoptysis,anorexia,loss of weight, hemoptysis,anorexia,loss of weight,
chest painchest pain

24. 6.Tuberculosis:-cough 6.Tuberculosis:-cough
(dry…purulent(dry…purulent
… …blood streaks in blood streaks in
sputum),sputum),
anorexia,LOW,anorexia,LOW,
night sweats,night sweats,
evening rise of evening rise of
temperaturetemperature

25. 7.ILD:-insidous onset exertional 7.ILD:-insidous onset exertional
dyspnoea,cough dyspnoea,cough
8.CHF:-exertional dyspnoea,cough, 8.CHF:-exertional dyspnoea,cough,
fatigue,orthopnea.PND,edemafatigue,orthopnea.PND,edema

26. 9.Sarcoidosis:-9.Sarcoidosis:-
cough,dyspnoea,erythema nodosum, cough,dyspnoea,erythema nodosum,
eye inflammation,fatigue,fevereye inflammation,fatigue,fever
10.Cystic fibrosis:-c/c or r/c cough 10.Cystic fibrosis:-c/c or r/c cough
with sputum,dyspnoea,wheeze, with sputum,dyspnoea,wheeze,
hemoptysis..young adult hemoptysis..young adult

27. 11.Post nasal drip;-nasal discharge… 11.Post nasal drip;-nasal discharge…
mucoid or mucopurulent,tickle in mucoid or mucopurulent,tickle in
throatthroat
12.GERD:-cough,heart burns, 12.GERD:-cough,heart burns,
regurgitationregurgitation

28. 13.Laryngeal inflammation:-cough, 13.Laryngeal inflammation:-cough,
hoarseness of voice,stridorhoarseness of voice,stridor
14.FB:-cough,stridor,history14.FB:-cough,stridor,history
15.ACEI:-dry cough starting within 15.ACEI:-dry cough starting within
1-6 months of treatment1-6 months of treatment

29. …THANK YOU