HISTORY TAKING

Dr. Don Gregory

1st year Junior Resident Dept. of TB & Chest Diseases

Govt. Medical College, Patiala

The HISTORY is a record or recitation of the patient’s symptoms

In diagnosis,the medical history is all- important,frequently surpassing in its diagnostic importance even a thorough physical examination

History taking is an art .The ability to elicit a good history comes with years of experience and knowledge

History taking helps to form a healthy Doctor-patient relationship

It also builds up the patient’s confidence and trust in his doctor

IMPORTANCE OF A GOOD HISTORY

Affords a lead in the right direction/clue to diagnosis

Eliminates certain diagnostic possibilitiesSuggests further avenues of investigationHelps to focus on system involvedEarlier proof of disease,since symptoms

usually precede signs

STARTING A CONSULTATION

The consulting room should be quiet and free from Interruptions Introduce yourself and clarify your role, giving the patient an

outline of what your intentions are Ensure the patient is comfortable. Listen to the patient, not merely hear Maintain Confidentiality with the patient Allow patient to recite in his own unhurried way Have a elasticity in interrogation Every symptom to be analysed thoroughly Leading questions to elicit symptoms omitted by patient

COMPOSITION OF A HISTORY

Preliminary data of the patientChief complaintsHistory of presenting illnessPast historyTreatment history including ATTFamily historyPersonal historyMenstrual history

PRELIMINARY DATA

Name of patient For establishing rapport

Father’s name Helps to differentiate two patients with same name

Age Helps to include or r/o certain diagnostic possibilities because of age trends of certain diseases .eg: Congenital anamolies are common in childhood. Degenerative , neoplastic, vascular ailments are more common in middle aged or elderly

young age-cystic fibrosis,BA,TBMiddle age-infections,BAOld age-COPD,lung cancer,pulmonary embolism.

Sex IHD, hemophilia , bronchogenic carcinoma have more affinity for male sex.Thyroid disorders,mammary cancers, autoimmune disorders are more in females

Religion Sikhs do not smoke and are less likely to develop symptoms related to smokingMuslims do not consume alcohol & are less likely to develop symptoms related to alcoholismCertain sects of Hindus do not consume meat products and are less prone to develop CA colon

Complete address Helps to know environmental factors /endemic factors eg: people from urban areas are prone to develop problems related to urbanization, people from hilly areas more prone to develop goitre , primary pulmonary HTNFor follow upHelps tracing patient in case of defaultEndemic diseases like filariasis,hydatidIndustrial area/environmental pollution leading to BA,pneumoconiosis,broncogenic ca,mesothelioma

Handedness Important in CNS disorders

CHIEF COMPLAINTS These are complaints for which patient comes to visit

the doctor If patient is not in a position to give history (moribund,

has loss of speech, in coma, mental illness )then it has to be asked with patient’s relative/attendant

These complaints should be recorded in a chronological order along with duration of the symptoms

e.g: cough-3 months Fever -1 month hemoptysis-3 days

HISTORY OF PRESENTING ILLNESS

Its elaboration of chief complaintsSymptoms are studied,analysed and recorded History is taken under the following headings:

Onset of the symptom, Duration and progression, Type, Diurnal and postural variation, Aggravating and relieving factors, Associated symptoms

Depending on which system or systems are involved on the basis of patient’s history, specific interrogation is done with a view to elicit maximum information about that system.eg:If patient has h/o cough, hemoptysis then suspicion would fall on respiratory system involvement and questioning is directed towards its other related symptoms.

Symptoms related to other systems is enquired to include or rule out multisystem involvement (Negative History extraction)

HISTORY OF ATT

Patient should be asked about any previous intake of ATT.If yes, following questions are asked:

Source from where drugs taken?Sputum microscopy and its results/reports?Any X-ray done?Type of treatment taken and its duration?Sputum microscopy result at the end of

treatment?Cause of irregularity in t/t if any?

PAST HISTORY This includes a review of: Any history of similar illness in the past Any past illness with a pointed reference to entities like Rheumatic fever, IHD Any H/o DM/HTN/asthma/epilepsy Any H/o childhood illness of exanthematous fevers eg:chicken pox,measles Any H/o traumatic lesions-pleural thickening can be a result of chest

trauma. Any H/o surgical intervention Any H/o blood transfusions and if any reactions Any H/o drug reactions/allergies Any H/o sexual exposure Countries of residence/travel : certain diseases like malaria ,

ankylostomiasis, amoebiasis and kala azar are more prevalent in the tropics and subtropics

animal exposure: pigeons-cryptococcaus,chicken-histoplasmosis,parrots-pisstacosis,sheep-Q fever

Importance of extracting an accurate past history The existing illness may be related to or be a sequel

of some past illness such as TB, Rheumatic fever ,IHD, syphilis, encephalitis or meningitis

History of asthma, malaria ,gout, epilepsy, amoebiasis, urticaria have a tendency to relapse/recurrence

Complications of uncontrolled states of DM, HTN can occur

HIV infection can cause opportunistic infections

If any past illness is present, enquiry is to be done regarding treatment received

TREATMENT HISTORY

This should include all previous medical and surgical treatment

Details of drugs taken including analgesics ,psychotropic drugs and of previous surgery and radiotherapy

Any drug allergy/ untoward reaction if occurred is to be enquired regarding its nature and severity so that same medication can be avoided in the patient in the future

Any medication that the patient may be continuing to take to the present date need to be asked to avoid any adverse drug reactions when new drugs are introduced

H/o intake of OCP and antiepileptics needs to be enquired

History regarding any long term anticoagulant therapy need to be asked

Antibiotics like macrolides and quinolones in recent past warrants use of different class of antibiotics

History regarding use of steroids need to be asked with its duration and dosage.

FAMILY HISTORY The family history affords information about the genotype or ”Inherited

make-up” of the patient Knowledge of an illness in the family can lead to early detection and

treatment Information about the immediate family may also have considerable

bearing on the patient’s symptoms. Enquiry should be made regarding disease state in family members,any early deaths in family

Disease in several members of family can be due to inheritance, contact, contagiousness or common environmental factors

When there is suspicion of a familial disorder, it is helpful to construct a family tree. If the pattern of inheritance suggests a recessive trait, ask whether the parents were related – in particular whether they were first cousins

Common diseases expressed in families include Hyperlipidaemia (IHD), DM, HTN, asthma, Myopia, Alcoholism, Depression, Osteoporosis, cancers , etc

PERSONAL HISTORY Education Gives information regarding highest degree attained Helps to know the age at which patient left school Helps in assessing diseases and disorders causing intellectual deterioration and social

function

Occupation Helps to assess his economic status Frequent job changes or chronic unemployment may reflect both socioeconomic

circumstances and the patient’s personality Gives a clue to exposure to Occupational hazards eg Farmers-EAA,moulds,parasitic lung disease Mining-silicosis,complicated TB Other non organic exposures like coal,asbestos lead to pneumoconiosis. Other problems such as depression, chronic fatigue syndrome and general malaise may

also be blamed on working conditions Presence of a disease may make patient unfit for his occupation eg: salmonella infection

in food handlers, epilepsy/colour blindness in drivers of public transport

Marital History Enquiry is made regarding consanguinity, duration of

marriage, health of spouse,no. of children Infertility may give a clue to the presence of immotile

cilia disorder, CF ,genital TB Developmental anomalies in offspring is enquiredSocial history-pets for HP Housing Housing conditions, no of family members, water

facilities ,sanitation Overcrowding can be a cause for TB, pneumonia.Appetite SleepBowel and bladder regularity

Sexual behaviour Enquiry Important mainly in long distant truck drivers h/o STD and HIV need to be enquired Habits Enquire h/o smoking/alcohol/tobacco/drug abuse If smoker ,calculate pack years or smoking index Pack yr=no.of cigarette packs smoked per day*no.of yrs smoking index=no.of cigarettes smoked per day*no.of yrs

A pack year of >40 OR smoking index of >400 is a risk for Bronchogenic carcinoma

Chullah exposure and passive smoking in females must be asked for. If alcoholic, calculate units of alcohol consumed. 1 unit is equal to 1/2 a pint of beer/ 1 glass of sherry/ 1 glass of wine/1

standard measure of spirits+ Alcoholics are more prone for aspiration, lung abscess,hypoventilation.+ Drug addicts may develop HIV,hepatitis,septic embolism,respiratory

depression.

MENSTRUAL HISTORYAge of menarcheMenstrual cycle : no of days of bleeding duration of cycle, associated pain and regularity of cyclesAny menstruation related chest pain : R/o

pulmonary endometriosisAny h/o amenorrhoea : R/o pregnancyObstetric history

MAIN SYMPTOMS IN RESPIRATORY DISEASES

Cough Breathlessness Chest pain Hemoptysis Fever Hoarseness of voice Hiccups

COUGH+ Cough is a sudden and variable expiratory thrust of air from the lungs and

through the air passages,associated with phonation,which momentarily interrupt the physiological pattern of breathing

+ Its a defense mechanism of the body to keep lower respiratory passages clear

+ The cough begins with a rapid inspiration, followed in rapid sequence by closure of the glottis, contraction of the abdominal and thoracic expiratory muscles, abrupt increase in pleural and intrapulmonary pressures, sudden opening of the glottis and expulsion of a burst of air from the mouth .The high intrathoracic pressures which often exceed 100 to 200 mmHg, increase the velocity of airflow through the airways, hastening the propulsion of the offending particles and producing the sound of a cough by setting into vibration airway secretions, the tracheobronchial walls, and the adjacent parenchyma

AFF:CN V(nose,sinuses),IX(post.pharynx),X(pericardium),phrenic. CENTRE:Medulla EFF:spinal motor(exp muscles),CN X(larynx,trachea,bronchi),phrenic N

CAUSES OF COUGH

1) Infections of respiratory tract: acute (laryngitis,tracheitis),chronic(Pulm TB,Bronchiectasis)

2) Mechanical irritation of respiratory tract:FB,inhalation of irritant gases,bronchogenic carcinoma

3) Reflex causes:irritation of vagus,FB/wax in EAC4) Extrapulmonary causes:these induce cough through

pressure on trachea/bronchus,infiltration of resp tract or secondary involvement of lung parenchyma eg:diseases of pleura,diaphragm or esophagus,aortic aneurysm,MS,LVF

5) Psychogenic6) Drug induced:ACE Inhibitors

METHOD OF INQUIRY

1) Onset Sudden:asthma,FB,inhalation of irritant gasesInsidious:pulmonary TB

2) Dry or productive Dry:URTI,inhalation of tobacco smoke,early PTBProductive:CB,lung abscess,bronchiectasis

3) Severity MildIrritating/disturbs sleep at night

4) Character Dry and irritable ,max on waking up:early PTBParoxysmal:Bronchial asthma,cardiac failure,whooping coughWith wheeze:Bronchial asthma,CB,tropical eosinophiliaBarking(harsh,loud,seal like):acute LTB,hysteriaBovine(cough loses its explosive character&becomes prolonged& wheezing): D/t involvement of RLN by tumoursStaccato(paroxysm ends in a stridulous inspiration):pertusisBrassy/metallic:mediastinal tumour/aortic aneurysm

5)Associated pain/distress pleurisy, pneumonia, rib fracture

6)Diurnal variation Early morning:COPD,PTB,bronchiectasis,allergy Nocturnal:asthma,pulmonary edema,chronic sinusitis,diaph.hernia

7)Postural variation/relief I/L side:pleurisy,pleural effusionC/L side:lung abscessSitting:LVF,COPD,diaphr.hernia

8)Relation to meals Increases on deglutition:developmental anamoly(BEF,TEF)Increases after meals:chronic lung disease

9)Associated features Cough syncope:chronic airway obstructionDysphagia:pressure on esophagus Change of voice:pressure on trachea/main bronchusFever:PTB,pneumonia,lung abscess, UTI

EXPECTORATION

Respiratory tract of normal adult produces 100 ml of sputum per day

If excess mucus is produced, its coughed out as sputum

1)Quantity •Scanty(< ¼ cup): URI•Copious( >¼ cup): CB,lung abscess,bronchiectasis,PTB

2)Colour Yellow:due to pus/leucocytesGreen :pseudomonas infectionRusty:pneumoniaPink,frothy:pulmonary edemaDark brown:amoebic liver abscess,lung fluke infection

3)consistency Thin watery: Pulmonary edemaThick viscid: asthma,CF Casts: ABPA,asthma, CB, CF

BRONCHORRHEA: PRODUCTION OF MORE THAN 100ML SPUTUM PER DAY.

SEEN IN BRONCHIECTASIS,LUNGABSCESS,ALVEOLAR CELL CARCINOMA

4)Foul smell Bronchiectasis,lung abscess, gangrene, malignant growth, bronchopleural fistula

5) Diurnal variation Early morning: asthma

6) Postural variation Seen in lung abscess,bronchiectasis

7)Hemoptysis Frank blood:TBStreaks of blood:TB, Chronic bronchitis

8)Presence of foreign body

Bronchial Casts seen in ABPA, AsthmaHooklets of hydatidSulfur granules of actinomycosis

BREATHLESSNESS(DYPSNOEA)

+ Dyspnea comes from the Greek word for hard breathing

+ It is the undue unpleasant subjective awareness of one’s own breathing characterized by increased respiratory effort and associated with distress ,discomfort or shortness of breath/air hunger

+ Often described as shortness of breath+ Its different from tachypnea which refers to increased

ventilation in proportion to increased metabolism or hyperventilation when increased ventilation is in excess of metabolic needs

GRADING OF DYPSNOEA GRADE Medical Research Council

(MRC) classificationNew York Heart Association(NYHA) classification

I Not troubled by Breathlessness except on strenuous exercise

No dypsnoea with ordinary activity

II Shortness of breath when hurrying or walking up a slight hill

Slight limitation of physical activity. Comfortable at rest

III Walks slower than his contemporaries on the level/ stops for breath when walking at his own pace

Marked limitation of physical activity/less than ordinary physical activity will lead to dypsnoea

IV Stops for breath after about 100 mtr or after a few minutes on the level

Inability to carry out any physical activity without discomfort. Dypsnoea present even at rest

V Too breathless to leave the house/breathless when dressing or undressing

CAUSES OF DYPSNEA

1) Dypsnoea on exertion Obstructive airway diseases:asthma,COPD, CB Restrictive lung diseases:pulmonary fibrosis Early heart disease: IHD, mitral stenosis Arrythmia,anxiety,obesity hyperdynamic states

2)Dypsnoea at rest Acute infections/mechanical

conditions:pneumothorax,pneumonia,pleural effusion Paroxysmal dypsnoea: acute LVF,asthma Metabolic causes:acidosis of uremia or diabetes Hyperthyroidism

ORTHOPNEA Its dypsnoea in supine position Occur within 30 seconds due to increase in left atrial pressure Causes include cardiac failure,decreased vital capacity seen in severe MS ,

pulmonary HTN TREPOPNOEA Dypsnoea in any of recumbent positions not due to CHF In cardiomegaly,patient feels discomfort in left lateral recumbent position

PLATYPNOEA Dypsnoea in upright position,relieved on recumbency Seen in left to right intracardiac pulmonary vascular shunting of

blood,pneumonectomy, constrictive pericarditis

PAROXYSMAL NOCTURNAL DYPSNOEA Dypsnoea at night which awakes the patient from sleep gasping for air& he sits or

stands to catch his breath Suggests cardiac cause of dypsnoea. Eg: LVF

METHOD OF INQUIRY1) Onset Acute:asthma,pulmonary edema,pneumothorax,FB etc

Chronic:COPD,pleural effusion etc

2) Time course Minutes:pneumothorax,pulmonary embolism, FB,pulm.edema due to arrythmia, laryngeal body,asthmaHours: LVF, PneumoniaDays: LVF,pneumoniaWeeks: pleural effusion,anemia,tumoursMonths:pulmonary fibrosis,muscle weaknessYears: COPD, chest wall disorders

3) Grading MRC/ NYHA grade

4)Recurrence Seen in bronchial asthma

5)H/o orthopnea, PND Suggests cardiac origin

6)Associated features Fever:suggest infective cause eg:pneumonia, PTBWheeze: asthma,acute exacerbation of COPDCough:asthma, PTB, bronchiectasisPedal edema:cardiac failure, anemiaJoint pain:ILD secondary to RASkin lesions: seen in SLE, scleroderma

+ h/o seasonal variation+ Occupational history+ Drug history

CHEST PAIN

+ Pain is an unpleasant perception caused by stimulation of sensory end organs and efferent tracts

+ Anterior thoracic pain is one of the commonest and most important symptoms of cardiovascular and respiratory diseases

+ Causes include thoracic,intrathoracic and extrathoracic causes

METHOD OF INQUIRY1)Onset Acute: pulmonary embolism, MI ,pericarditis, trauma

2)Site Substernal :Angina , MILateral chest wall: pleurisyAnterior chest:aortic dissection Epigastrium: peptic ulcer diseaseLocalised pain: rib fracture,tumours involving pleura/ribIn distribution of thoracic nerves:Herpes zoster

3)Type Pressing, constricting ,vice-like heaviness in anginaSharp,severe pain aggravated on coughing & inspiration in pleurisyConstant, boring pain in aortic aneurysm & malignant tumours of mediastinumSevere tearing pain in dissecting aneurysmDull poorly localised central chest pain in large central tumours

4)Radiation of pain Pain of angina/ MI radiates to left shoulder/arm, neck or jawPain of aortic dissection radiate to interscapular region

5) Referred pain Central diaphragmatic inflammation pain is referred to tip of shoulder and of lateral part to lower lateral chest wall and abomen

6) Aggravating factors Exercise ,excitement in anginaCoughing,inspiration, lying on same side in pleuritic painSwallowing in esophageal disordersCoughing,sneezing ,straining in musculoskeletal painCoughing ,swallowing, twisting trunk in pericarditis

7)Relieving factors Nitrates relieve pain in anginaPericarditis pain abated by leaning forward in sitting posture

8)Duration of pain anginal pain lasts usually for few secondsPain of neurocirculatory asthenia lasts hours to days

9)Associated features sweating ,dypsnoea in MIHemoptysis in pulmonary infarctionFatigue ,palpitation in MVP

HAEMOPTYSIS

+ It is the coughing out of blood + Its a indicator of serious disease of respiratory tract+ Can be confused with hemetemesis+ Coughed up blood is usually bright red and frothy

whereas Vomited blood is usually clotted, darker, non frothy, contains food particles and acid in reaction.

+ Haemoptysis originates from bronchial arteries( 95%) or pulmonary arteries(5%)

+ Massive haemoptysis is coughing more than 400ml in 3 hrs or 600 ml blood within 24 hours.seen in TB, Bronchiectasis,CB, bronchogenic carcinoma

CAUSES OF HAEMOPTYSIS

+ Infections+ Bronchitis+ Tuberculosis+ Fungal infections+ Pneumonia+ Lung abscess+ Bronchiectasis+ Neoplasms+ Bronchogenic carcinoma+ Bronchial adenoma+ Cardiovascular disorders+ Pulmonary infarction from thromboembolism+ Mitral stenosis+ Trauma+ Foreign body+ Hematologic/immunologic+ Blood dyscrasia+ Goodpasture’s syndrome

+ Massive hemoptysis-TB,bronchiectasis,broncogenic ca,suppurative pneumonia,thromboembolism.

+ Scanty hemoptysis-broncogenic ca,chronic bronchitis,thromboembolism

+ Hemoptysis with streaks-bronchiectasis,chronic bronchitis,pneumococcal

+ Recurrent hemoptysis-broncogenic ca,chronic bronchitis,TB,bronchiectasis

METHOD OF INQUIRY1) Age Childhood and adults: Bronchiectasis, TB , MS

Middle and old age: bronchogenic carcinoma

2) Quantity Mild: early PTB , acute/chronic bronchitisProfuse:advanced PTB, MS, bronchogenic CA,

3)Presence of sputum Blood is mixed with sputum in infectious causesFresh blood without sputum in non infective causes

4)H/o trauma eg: gun shot wounds / fracture of ribs

5) Associated symptoms

Cough. fever.,night sweats ,loss of wt in TBH/o Recent operation/phlebitis in pulm infarctionDypsnoea, palpitation in Mitral stenosisBleeding from other sites is s/o blood dyscrasiasH/o smoking in old age is s/o bronchogenic CACough with foul smelling sputum s/o lung abscess

FEVER

+ The mean oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels at 6 a.m. and higher levels at 4-6pm

+ The maximum normal oral temperature is 37.2°C (98.9°F) at 6 a.m. and 37.7°C (99.9°F) at 4 p.m

+ Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings

+ Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point

+ An a.m. temperature of >37.2°C (>98.9°F) or a p.m. temperature of >37.7°C (>99.9°F) defines a fever

+ A fever of >41.5°C (>106.7°F) is called hyperpyrexia. This extraordinarily high fever can develop in patients with severe infections but most commonly occurs in patients with central nervous system (CNS) haemorrhages

+ Hyperthermia is characterized by an uncontrolled increase in body temperature that exceeds the body's ability to lose heat. The setting of the hypothalamic thermoregulatory centre is unchanged

METHOD OF INQUIRY1)Onset of fever Sudden: Pneumonia, URI

Gradual: Typhoid fever2) Severity of fever Mild grade: 99-100F

Moderate grade: 100-103FHigh grade: >103FHyperpyrexia: >106.7F

3) Type Remittent: Temperature does not touch normal at all and the diurnal variation exceeds 1.5F eg: typhoid , Infective endocarditisContinuous: Temperature does not touch normal at all but the diurnal variation is less than 1.5F eg: pneumonia, typhoid, UTIPeriodic/Relapsing: Here fever occurs in bouts lasting for days with afebrile phases eg:brucellosis, hodgkins lymphomaIntermittent/septic/hectic: Here fever remains for few hours and then temperature touches baseline. Its of 3 types

Quotidian: intermittent fever that occurs dailyTertian: intermittent fever on alternate daysQuartan: intermittent fever on every 4th day

4) Associated chills and rigors

Seen in lobar pneumonia, malaria, pyelonephritis, malaria, sepsis,infective endocarditis

5) Relieved with antipyretics?

Hyperthermia is not relieved by antipyretics

6)Associated features h/o evening rise of temperature: Seen in cases of TBh/o burning micturition: seen in UTIh/o cough with sputum: respiratory infectionsh/o diarrhoea ,vomiting: gastroenteritish/o rash: typhoid, meningococcemia,SLE etch/o arthralgia: dengue, chikungunya

HOARSENESS OF VOICE

+ A voice that is rough, harsh and lower in pitch than normal is usually described as hoarse

+ Its usually due to interference with the phonation function of larynx

+ Causes include Inflammatory lesions of larynx:laryngitis, diphtheria, TB, syphilis New growths:papiloma/fibroma/hemangioma Paralysis of vocal cords:medullary damage

(infarction,syringobulbia), RLN palsy ( following thyroid surgeries,aortic aneurysm,bronchial neoplasms)

Myasthenia gravis Voice abuse

METHOD OF INQUIRY1) Onset Acute febrile onset in infectious laryngitis/diphtheria

2) Duration Hoarseness associated with ARI is self limited and does not last more than 2-3 weeks

3) Occupation More common in voice abusers like singers ,teachers

4) Pain TB of larynx causes pain localized to laryngeal area or referred to adjacent structures such as ear

5) h/o any trauma/thyroid surgery

Suggests injury to RLN

6) Associated Dypsnoea Bilateral PTB, mitral disease, aortic aneurysm,pericardial effusion

7) Aphonia Aphonia but normal sound on coughing suggests Hysteria

HICCUPS

+ Sudden, involuntary, contraction of the diaphragm (usually unilateral) and other inspiratory muscles terminated by abrupt closure of the glottis

+ Occurs as a result of stimulation of one or more limbs of the hiccup reflex arc:– Involves irritation of the vagus and phrenic

nerves(afferent)– The hiccup centre is located in the upper spinal cord�– Efferents travel through phrenic nerve

+ Male-to-female ratio is 4:1:– In men, more than 90% of cases have an organic basis.– In women, a psychogenic cause is more likely

CAUSES OF HICCUPS

+ Idiopathic+ Gastrointestinal:

– Gastric distention– Esophageal lesions– Reflux esophagitis/achalasia– Hepatic /pancreatic lesions– Appendicitis– Abdominal aortic aneurysm– Postoperative, abdominal procedure

+ Head and neck:– Otic foreign body irritating the tympanic

membrane– Pharyngitis/laryngitis– Retropharyngeal/peritonsillar abscess

+ Diaphragmatic irritation:– Hiatal hernia– Tumors– Pericarditis– Eventration– Splenomegaly– Hepatomegaly– Peritonitis

+ CNS lesions:– Encephalitis– Subarachnoid hemorrhage/stroke– Arteriovenous malformations– Parkinson disease/multiple sclerosis

+ Mediastinal and other thoracic lesions:– Pneumonia– Aortic aneurysm– Tuberculosis– Myocardial infarction– Lung cancer

+ Metabolic causes:– Uremia/dm/gout– Hypocalcemia/natremia

+ Toxic/drug-induced:– barbiturates

+ Psychogenic causes:– Stress/excitement– Grief– Malingering– Conversion disorder

ADDITIONAL HISTORY TO BE TAKEN

PALPITATIONPEDAL EDEMAWEIGHT LOSS LOSS OF APPETITEABDOMINAL PAINURINARY AND BOWEL COMPLAINTS

RESUME AND DIAGNOSTIC IMPRESSIONS

At the end of the history ,a short summary outlining the salient or important facts of the case is prepared

The diagnostic impressions or tentative conclusions of the examiner are then added

This narrows down the subsequent field of exploration and cut out unnecessary examinations or investigations

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