History taking

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Collected By Dr. Partho Shil (DMF, Dhaka)
History Taking
Contents
Fever:...................................................................................................................................................................2
Weight Loss.........................................................................................................................................................5
Generalized swelling: ..........................................................................................................................................7
VOMITING :.......................................................................................................................................................9
Haematemesisis & Melaena ..............................................................................................................................11
Dysphagia ..........................................................................................................................................................13
Dyspepsia ..........................................................................................................................................................15
Diarrhoea ...........................................................................................................................................................17
Constipation.......................................................................................................................................................20
Jaundice .............................................................................................................................................................22
Abdominal Distension.......................................................................................................................................24
Cough and Expectoration..................................................................................................................................26
Haemoptysis ......................................................................................................................................................31
Breathlessness....................................................................................................................................................33
Chest Pain..........................................................................................................................................................35
Palpitation..........................................................................................................................................................38
Polyuria..............................................................................................................................................................40
Pain Lumbar Region..........................................................................................................................................42
Haematuria ........................................................................................................................................................44
Muscular Weakness...........................................................................................................................................46
Headache ...........................................................................................................................................................50
Fits (Seizures)....................................................................................................................................................54
Vertigo...............................................................................................................................................................57
Pallor (Anaemia) ...............................................................................................................................................59
Bleeding Tendency............................................................................................................................................60
Itching (Pruritis) ................................................................................................................................................61
Joint Pains..........................................................................................................................................................62
Syncope (Fainting) ............................................................................................................................................65

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Fever:
CHIEF COMPLAIN:
1. Fever for .............days.
COMMON CAUSES:
1. Protozoal infections: Malaria
2. Bacterial infections: Typhoid and Paratyphoid fever, TB, Pneumonia, Brucellosis,
Pyelonephritis, Lung abscess, empema or subphrenic abscess.
3. Viral Infection: Influenza, Measles, Mumps or Chicken Pox.
4. Autoimmune diseases: Rheumatic fever, Rheumatoid arthritis, SLE, Dermatomyositis.
5. Malignant disease: Lymphomas, Leukaemias and hypernephroma.
6. Iatrogenic fever: Drug Induced
7. Habitual hyperthermia.
HISTORY OF PRESENT ILLNESS:
1. DURATION:
Short : Viral Infection, Pharyngitis or Tonsillitis, Pyogenic Meningitis, Pneumonia, Acute Malaria etc.
Long : Chronic Malaria, Enteric fever, TB, Brucellosis, Autoimmune diseases and Malignant
Diseases.
However much depends on when the patient to see a doctor.
2. ONSET:
Sudden : Malaria, Abscess anywhere, viral infection.
Gradual : Entric fever, TB, Brucellosis, Collagen and malignant disease
With rigor : Malaria, Septicemia and pyogenic infection.
3.SEVERITY: Ask about the temperature if it has been noted and check where it is
Low grade : TB, Brucellosis, Collagen and malignant disease
Moderater
Or High grade
: Dengue, Malaria, Enteric fever,
Can occur during some stage of any fever.
Also keep in mind that the temperature might have changed because of the use of antipyretics and
cold sponging.
4.CHARACTER OF FEVER:
Intermittent : Fever which is present for few hours only and then touches normal. If so note the
periodicity of fever whether it is quotidian i.e occurring daily (Pyelonephritis, empyema,
abscess anywhere and malaria due to more than one type of plasmodia) or tertian ie
occurring on every fourth day (Malaria due to Plasmodium vivax, ovale and falciparum
infection) or quartern i.e. occurring every fourth day (Malaria due to plasmodium
malariae Infection).
Remittent : Fever which fluctuates more than 20C in 24 hours and does not touch the baseline (Entirc
fever, Occasionally other fevers)
Continued : Fever which fluctuates less than 10C in 24 hours and does not touch the baseline (TB and
Most of the other fevers)
Pel-Ebstein or
undulant fever
: Which is present for a few days to weeks only to repeat itself in this fashion (Bucellosis
and Hodgkin’s Lumphoma).
5. DIURNAL VARIATIONS: Like normal Temperature in most of the case of fever, temperature is
higher in the evening than in the morning. However a significant evening rise of temperature suggest TB,
Brucellosis and lymphomas.
6. ASSOCIATED SYMPTOMS:
a. Headache and neck stiffness (Meningitis, encephalitis and subarachnoid haemorrhage.)

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b. Cough, chest pain and expectoration of rusty sputum (Lobar pneumonia).
Copious amounts of foul smelling sputum more in the morning (Lung abscess and
bronchiectasis) or haemoptysis (Pulmonary TB, bronchiectasis or Pulmonary Infarction)
c. Diarrhoea with watery stools (Viral gastroenteritis) or diarrhoea with bloody stools (Bacillary
dysentery, Ulcerative colitis or Crohn’s disease)
d. Sore throat (Pharyngitis or tonsillitis)
e. Dysuria and Pain in the lumbar regions or hypogastrium (Pyelonephritis)
f. Joint pain, swelling and redness (Rheumatic fever, RA, SLE and septic arthritis)
g. Enlarged Lymph nodes (TB, Hodgkin’s and Non- Hodgkin’s Lumphoma, acute leukaemias
and infection mononucleossis)
h. Rash (Measles, Chickenpox, Rheumatic fever, drug reaction, SLE, and infection
mononucleossis).
i. Jaundice following fever (Viral hepatitis and haemolytic anaemias), Jaundice with fever
(Cholangitis)
j. Apparent good health without any anorexia or weight loss or other associated symtoms
(Habitual Hyperthermia or fictitious fever)
PAST HISTORY:
Ask about a past history of malaria, entric fever and TB and whether proper treatment was given
(These diseases tend to relapse if inadequately treated). Ask about Similar disease in the past (Collagen
disease and IBW (Inflammatory bowel disease) May have remissions or exacerbations). A Past history of
abdominal symptoms or operation may be a clue to such-phrenic abscess.
FAMILY HISTORY:
Ask about similar symptoms in other family members (Viral hepatitis, TB or Typhoid fever).
PERSONAL HISTORY:
a. Occupational history. e.g. Shepherd, Milkman (Brucellosis), Medical profission (Viral
hepatitis, TB or Fictitious fever).
b. Living Condition e.g. Supply of contaminated water (Typhoid fever, bacillary dysentery),
Overcrowded living condition (TB).
c. Travel abroad (Gonorrhea, Syphilis, drug resistant malaria, trypnosomiasis and AIDS).
d. Hobbies e.g. Keeping pigeons or parrots (Psittacosis).
DRUG HISTORY:
Note all drug being taken by the patient as they may not only a clue to the diagnosis but may also be
the cause of fever.
DIFFERENTIAL DIAGONOSIS:
1. Malaria: The fever is sudden in onset with rigors, high grade, intermittent and depending upon the
plasmodium causing infection it may be quotidian (Plasmodia of different types), tertian (Plasmodium vivax,
ovale and falciparum) or quartern (Plasmodium malaria). Untreated fever may continue for weeks to months,
although in such cases fever becomes low grade or may be absent. Symptoms in such cases may be because
of anaemia and Splenomegaly. (Chronic malaria). There is a good response to antimalarials and fever
subsides by crisis with profuse sweating.
2. Enteric fever: The fever is gradual, remittent reaching a peak of high grade in about 3 to 5 days.
Untreated fever usually lasts for about four weeks unless the course is altered by specific treatment. Fever
subsides by lysis. At the onset there is a prodrome of headache, dry cough and generalized malaria. Anorexia
is prominent with constipation initially followed by diarrhoea later on.

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3. Tuberculosis: The fever is gradual in onset, low grade, continued or intermittent with evening rise
and associated with night sweats, weakness, anorexia and weight loss. Depending upon the site of infection
there may be neck rigidity with or without paralysis and disturbance of conscious level (Meningitis). Cough,
Breathlessness, expectoration and sometimes haemoptysis (PTB) or abdominal pain with diarrhoea
alternating with constipation which may be followed by abdominal distension (Illeocaecal Tuberculosis and
subsidence of fever with weight gain and relief of other associated symptoms.
4.Habitual hyperthermia: The usually occurs in young neurotic woman with a long-standing history
of low grade fever with afternoon temperatures between 100 and 100.50F. Associated with fever usually
nonspecific complaints without any weight loss. These patient often keep a detailed record of temperature
and investigation which are usually normal. Reassurance, removal of the patient from her stressful life
situation with or without tranquilizers often result in disappearance of fever.

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Weight Loss:
CHIEF COMPLAINTS:
1. Weight loss for ........days.
2. Weakness for............days.
COMMON CAUSES:
1. Infection: TB
2. Endocrine Disease: Insulin dependent diabetes mellitus, hyperthyroidism and Addison’s disease.
3. Liver disease: Acute and Chronic viral hepatitis, Cirrhosis of Liver.
4. Chronic Renal failure.
5. Malignant Disease: Lymphomas, Leukemia’s, Carcinoma of stomach, colon, liver, Pancreas and
lung.
6. Blood disease: All types of anaemia.
7. Psychological problems: Anorexia nervosa, anxiety and depression.
8. Malabsorption syndrome.
1. Documentation of weight loss: Actual weight loss can only be documented if the previous and the
recent weight is known. For a rough guide enquire whether the collar size of the shirt or the waist size of the
trousers has decreased or the rings worn in the hands have become loose or the clothes appear loose.
2. Duration: Whether recent and rapid (more significant) or long standing and slow (less significant).
3.Appetite: Increased (Hyperthyroidism, Insulin, IDDM, worm infestation and malabsorption
syndrome), decreased (Addison’s diseas, psychological disturbances, renal failure, viral hepatitis and
malignant disease).
4. Dietary habits: Enquire about the quantity of food taken daily and any specific food excluded?
Particularly note the exclusion of carbohydrates (Anorexia nervosa), Carbohydrates and fat (Dieting),
Proteins ( Carcinoma of the stomach) or fats (because of intolerance in carcinoma pancreas and gall-bladder).
5. Associated Symptoms:
a. Cough, expectoration with or without haemoptysis and fever with evening rise of temperature
(Pulmonary Tuberculosis).
b. Jaundice (Acute or Chronic Hepatitis and carcinoma of pancreas) or distension of the abdomen
(Cirrhosis liver).
c. Nausea, vomiting, metallic taste of the mouth with oliguria or polyuria (Renal failure)
d. Pass of worm in the stool (Worm infestation).
e. Intolerance to heat, tremors, excessive sweating, thyroid swelling (Hyperthyroidism).
f. Polyuria, polydipsia and polyphagia (IDDM)
g. Excessive worry about body image and being overweight (Anorexia nervosa) or difficulty in
going to sleep, palpitation and fatiguibility in a worrier (Anxiety neurosis) or worthlessness,
self-depreciation, early morning waking with or without suicidal thoughts (Depression).
h. Dyspepsia, vomiting with or without haematemesis (Carcinoma stomach), recent constipation,
tenesmus and blood in the stools (Ca of colon or rectum).
i. Lymph node enlargement (TB lymphadenitis, lymphomas and lymphocytic leukemias)
j. Passage of bulky, offensive, froth and sticky stools (Malabsorption syndrome).

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PAST HISTORY:
Of any significant illness (operations, treatmnt of malignant disease or renal problems), any history of
passage of worms in the stools (Helminthiasis) or previous blood transfusions or injection (Viral hepatitis).
FAMILY HISTORY:
Strict family set up or marital problems in parents (Anorexia nervosa), family history of DM.
PERSONAL HISTORY:
Of patient being a worrier (Anxiety state), any recent upset in life, e.g. failure in examination, loss of
job, financial loss or death of near relative (Reactive Depression), History of heavy smoking (Ca Lung) or
drinking (Cirrhosis liver), profession as farmer (Worm infestation).
DRUG HISTORY:
Enquire about any drug taken by the patient in the past and recent particularly about Digoxin,
Fenfluramine and Insulin or other anti-diabetic agents.
DIFFERENTIAL DIAGNOSIS:
1. TB
2. Viral Hepatitis
3. DM
4. Hyperthyroidism: The patient is usually a female who complains of weight loss despite
normal or increased appetite. Associated symptoms include intolerance to hot weather,
excessive sweating, palpitations, insomnia, irritability and thyroid enlargement. The patient or
the relatives might have noticed prominent eyes. Sometimes diarrhoea may also occur.
5. Addison’s Disease: The patient complains of weight loss, anorexia, nausea, vomiting,
abdominal pain, diarrhoea, lethargy and weakness. Darkening of the skin may be noted be the
patient or the relatives. Rarely depigmentation of the skin may also be symptom.
6. Anorexia nervosa: Usually the patient is a young female brought by the relatives on account
of extreme weight loss and refusal to eat. On eating anything vomiting is often induced. The
patient often thinks herself to be obese and selectively excludes carbohydrates from the diet.
Despite the severe degree of cachexia over activity is common. Sleep is often poor but the
patient often awakes fresh. Amenorrhea is usual. Disturbed parent relationship is usual.

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Generalized swelling:
CHIEF COMPLAIN:
1. Swelling of body/face/leg for .............days.
COMMON CAUSES:
1. Cirrhosis liver
2. CCF
3. NS (Nephrotic Syndrome)
4. Myxoedema
5. Angioedema
HISTORY OF PRESENT ILLNESS
1. Duration and onset:
Short history with sudden onset (Angioedema). Long history with gradual onset (CCF,
Cirrhosis liver, NS and Myxoedema).
2. Sites involved:
a. Starting on lower eye lids and face as bogginess esp. on waking, later on extending to the
abdomen and feet (Nephrotic Syndrome).
b. Staring from the abdomen and then extending to the feet and rarely to rest of the body
(Cirrhosis liver).
c. Starting from the feet, extending to the legs and then abdomen (CCF)
d. Generalized puffiness of the whole body (Myxoedema).
e. Involvement of the eye lids and lips, very rarely rest of the body (Angioedema).
3. Effect of posture and pressure:
Increased on the feet by walking, standing or sitting with the legs hanging and pressure
causing a depression or pit on the affected area i.e. pitting oedema (Cirrhosis liver, CCF, NS),
no effect of posture and pressure (Myxoedema & Angioedema).
a. Breathlessness on exertion, orthopnoea (The inability to breath easily except when sitting up
straight or standing erect), Paroxysmal nocturnal dyspnoea, pain right hypochondrium and
palpitations (CCF).
b. Oliguria and discomfort in lumbar regions (NS, rarely in CCF and Cirrhosis of liver).
c. Lethargy, sleepiness, intolerance to cold, hoarseness of voice, constipation and dizziness
(Myxoedema).
d. Itching with formation of weals at the site of itching (Angioedema).
5. Aggravating symptoms:
Intake of salt (CCF, Cirrhosis liver & NS) use of drug or diet to which the patient is allergic
(Angioedema).
6. Relieving factors:
Diuretics (CCF, Cirrhosis liver & NS), Thyoxine (Myxoedema),
Anti-histamines and steroids (Angioedema).
7. Progression:
Progressively worse unless treated (CCF, Myxoedema, Cirrhosis liver & NS),
Attacks at variable intervals (Angioedema).

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PAST ILLNESS
Ask about past history suggestive of:
a. Jaundice (Cirrhosis liver)
b. Angina pectoris, heart attack, hypertension or Rheumatic fever (CCF)
c. Sore throat (NS)
d. Drug or food allergies causing urticarial rash (Angioedema).
e. Thyroid operation (Myxoedema).
FAMILY HISTORY
Nothing contributory.
PERSONAL HISTORY
DRUG HISTORY
DIFFERENTIAL DIAGNOSIS
1. Cirrhosis liver: Often there is a past history of jaundice although this history may be absent. The
swelling first appears on the abdomen and later on extends to the feet. It is increased by walking,
standing or sitting with feet dependent and by salt intake. There may be history of heaviness in the left
hypochondrium (due to splenomegaly) or haematemesis and melaena (due to oesophageal varies
and/or peptic ulcer). Diuretics relive the symptoms to a variable extent.
2. Congestive cardiac failure (CCF): The swelling starts gradually on the dependent parts (Feet and
legs while standing, walking or sitting and on the sacral area while lying). Abdomen may be involved
later on although this rare. This symptom is usually associated with other features of CCF i.e.
breathlessness on exertion, Orthopnoea, paroxysmal nocturnal dysponea and pain in right
hypochondrium, sometimes with jaundice due to hepatic congestion. There may be a past history
suggestive of Rheumatic fever, hypertension or angina. The symptoms of CCF are relieve by diuretics
or digoxin and worsened by intake of salt.
3. Nephrotic Syndrome: Usually the swelling is first noted as bogginess of the lower eye-lids on
waking up from sleep. Later on it extends to abdomen and feet. The swelling is gradual, painless and
pitting. There may be associated oliguria, anuria and heaviness in the lumbar regions. Past history
may reveal use of kushtas or nephrotoxic drugs or symptoms of sore throat.
4. Myxoedema: The patient who is often a female presents with generalized, gradual, painless, non-
pitting swelling. There may be a past history of thyroid surgery. Associated symptoms of lethargy,
somnolence, hoarseness of voice, weight gain despite poor appetite, loss of hair and intolerance to
cold often help to clinch to diagnosis. Swelling and other symptoms gradually improve by thyroid
replacement therapy.
5. Angioedema: The patient who often who often has a history of allergy to drug or food complains of
attacks of itching with weal formation which may progress to puffiness of the eyelids and lips with
suffocation and difficulty in breathing. Symptoms are often recurrent and are relieved by anti-
histamines, steroids or subcutaneous adrenaline.

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17. Endocrinal disorder:
Chronic renal failure
Addison’s disease
Diabetic ketoacdidosis and hyper calcaemia.
18. Pregnancy
19. Obstructive lesions: Pyloric stenosis,
Intestinal Obstruction
20. Psychogenic vomiting
21. Drug induced: Digoxin, Iron, Potassium chloride
Oestrogens and bronchodialators.
22. Colic (Renal, billiary or intestinal)
23. Febrile illness.
VOMITING :
CHIEF COMPLAIN:
1. Vomiting for .............times.
COMMON CAUSES:
1. Migraine
2. Acute vestibular failure
3. ↑ ICP (Intracranial pressure)
4. Meningitis
5. MI (Myocardial infarction)
6. Acute viral hepatitis
7. PUD (Peptic ulcer disease)
8. Viral hepatitis
9. Gastric erosion
10. Acute pancreatitis
11. Acute cholecystitis
12. Acute cholelithiasis
13. CKD (Chronic kidney disease)
14. AGN (Acute glomerulonephritis)
15. Diabetic ketoacidosis
16. Diabetic nephropathy
1. Frequency: How many times in 24 hours? This does not help in making a diagnosis but helps to judge
the severity of the vomiting and the need of urgency for treatment.
2. Type of vomiting: Whether projectile (Raised Intracranial pressure, rarely pyloric stenosis), or non-
projectile (Most other causes).
3. Timing of vomiting: Early morning even without or before eating (Pregnancy, Alcoholism, Uraemia,
Chronic bronchitis and sometimes in psychogenic vomiting), no definite timing (All other causes).
4. Relation to meal: Immediately following meals (Anorexia nervosa, disorders of the throat and upper
esophagus), half to one and a half hours after meals (PUD) no relation to meal (Endocrine disorders
and most other causes).
5. Character of the vomiting:-
a. Contents: Food eaten upto two hours ago (Gastritis, gastroenteritis, PUD, endocrine causes),
partially digested food eaten upto 24 hours previously (Pyloric stenosis and small intestinal
obstruction).
b. Colour: Yellowish i.e. containing hydrochloric acid (Pyloric stenosis and obstructive jaundice),
yellowish green or greenish i.e. containing bile (all disorder without obstruction to the bile flow),
coffee ground or bloody i.e. haematemesis (Ruptured oesophageal varices, bleeding PUD, gastric
erosions, gastric carcinoma, uraemia and sometimes bleeding disorder).
c. Odour (smell): Acrid (Disorders of the stomach), faecal (Intestinal obstruction or gastrocolic
fistula, rarely with paralytic ileus), putrid (Bacterial overgrowth of retained gastric contents or in
fungating gastric carcinoma).
6. Associated symptoms:
a. Burning or cutting epigastric or right hypochondrial pain relieved by vomiting or antacids (PUD).

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b. Pain right hypochondrium with or without jaundice (Viral hepatitis, Acute cholecystitis or
pancreatitis)
c. Colicky abdominal pain (Intestinal, renal or biliary colic).
d. Diarrhoea (Viral or bacterial gastroenteritis, sometimes Addison’s disease, diabetic ketoacidosis,
thyrotoxicosis and renal failure).
e. Constipation (Hypercalcaemia and intestinal obstruction).
f. Polyuria and polydipsia (Diabetic ketoacidosis, Uraemia and hypercalcaemia).
g. Amenorrhea in a female of child bearing age (Pg or Heyperemesis gravidarum).
h. Unconciousness (Uraemia, Addison’s disease, diabetic ketoacidosis, raised intracranial pressure).
i. Headache (Migraine and raised intracranial pressure due to meningitis, encephalitis or space
occupying lesion of brain).
j. Attacks of vertigo and deafness (Meniere’s disease).
7. Aggravating factor: Spicy food (PUD), emotional upset (Psychogenic vomiting), meat (Ca of
stomach)
8. Relieving factor: Milk or antacids or ulcer healing drugs (PUD)
PAST ILLNESS
1. Dyspepsia (Peptic Ulcer, Pyloric stenosis and carcinoma stomach).
2. Diabetes mellitus (Diabetic Ketoacidosis)
3. Renal Colic, Dysuria, Oliguria or anuria (Uraemia)
4. Abdominal operations (Intestinal Obstruction)
5. Contact with jaundice patient or injection or blood transfusion (Viral hepatitis).
FAMILY HISTORY
PERSONAL HISTORY
DRUG HISTORY:
Ask about a history of the use of NSAIDs, Digoxin, opiates, Iron preparation, Potassium chloride,
oestrogens, aminophylline and other bronchodialators.
1. Gastroenteritis
2. PUD
3. Viral hepatitis
4. Chronic renal failure
5. Migraine
6. Addison’s disease
7. Meneier’s disease

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Haematemesisis & Melaena
CHIEF COMPLAIN:
1. Passage of Bloody vomiting for .............times.
2. Passage of Black tarry stools for .............Days.
COMMON CAUSES:
Haematemesisis
1. PUD
2. Gastric erosion
-NSAID
- Alchole
- Steroid
3. Gastric carcinoma
4. Rupture oesophageal Variases
5. Esophagitis
6. Bleeding disorder (Hemophilia)
7. Patient in anticoagulant
1. Color of blood in the vomiting: Dark red or coffee ground (Old or slow bleeding), bright red (Recent
or massive rapid bleeding). This may help to assess the gravity of the situation.
2. Quantity of blood: Ask how many times Haematemesis or Melaena has occurred and the rough idea
of how much blood has been lost.
3. Melaena stools: Ask about passage of melaena stools, i.e. black tarry, semisolid stools. This usually
indicates moderate upper GIT bleeding and follows haematemesis by 12 to 24 hours. It may be absent
if the bleeding is slow and no vomiting occurs. Passage of fresh blood per rectum with haematemesis
usually indicates massive and rapid bleed with rapid transit to the rectum.
4. Precipitating factors: Enquire about the use of Non-steroidal anti-inflammatory drug (NSAID),
steroids (Gastric erosions) or alcohol (Mallory Weiss Syndrome).
a. Symptoms of anaemia depending upon severity (See under ‘Pallor’).
b. Chronic headache or joint disease (Gastric erosions due to the use of NSAIDs)
c. Symptoms of dyspepsia (Peptic Ulcer)
d. Discomfort in the left hypochondrium and abdominal distesion (Oesohageal varices due to
cirrhosis liver). However, varices may bleed before these symptoms can develop.
e. Anorexia, weight loss and asthenia (Gastric carcinoma).
f. Bleeding from other sites e.g. Gums, nose or skin (Bleeding Diathesis).
PAST ILLNESS
1. Jaundice and/or ascites (Oesophageal varics due to cirrhosis liver).
2. Similar episodes of haematesis or melaena (Chances of second bleeding for much more in patients
with previous such history).
FAMILY HISTORY
Nothing Contributory
PERSONAL HISTORY
Melaena
1. Chronic gastric ulcer
2. Chronic duodenal ulcer
3. Gastric erosion
4. Carcinoma of stomach
5. Hookworm infestation
6. Haemorrhagic disorder

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DRUG HISTORY
History of NSAIDs, Steroids (Gastric erosions) intake may be present.
1. Esophageal varices: Haematemesis is often sudden, massive and difficult to control. Other
symptoms of cirrhosis liver (See under “Generalized Swelling’) may or may not be present as may
be a past history of jaundice.
2. Gastric erosions: There is often history of sudden massive unexpected haematemesis and melaena
which is often associated with pain epigastrium. Usually the patient has been taking steroids or
NSAIDs. A past history of dyspepsia may or may not be present. These symptoms may improve
either spontaneously or on stopping the offending drug or respond to antacids or ulcer healing drugs.
3. Peptic Ulcer: (See under ‘Dyspepsia).
4. Gastric carcinoma: The Patient is often an old person complaining of haematemesis and melaena
which is usually painless, although pain in the epigastrium may be present. The history may be recent
with anorexia, weight loss and symptoms of anaemia. Sometimes there may history of severe distaste
for meat. Symptoms of dyspepsia usually persist in between meals. Lack of response of chronic
dyspepsia to antacids which is hitherto responsive also indicates malignant change in chronic gastric
ulcer.
5. Bleeding disorders: (See under “Bleeding Tendency).

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Dysphagia
Difficulty in swallowing is called Dysphagia. Although usually painless it may be painful. There is
usually a sensation of food sticking in the retrosternal area. In most cases dysphagia is experienced at the
same level as the lesion or above it but not below it.
CHIEF COMPLAIN:
1. Difficulty in swallowing for .............hours/ day.
COMMON CAUSES:
1. Oropharangeal cause: Acute tonsillitis (Common), Peritonsillar abscess, bulbar and pseudobulbar
palsy, myasthenia garvis (rare).
2. Oesophgeal cause: Foreign body, peptic oesophagitis (common), carcinoma oesophagus, caustic
stricture (occasional), Achlasia, sclerodema, diabetic neuropathy, Plummer Vinson’s syndrome (rare)
3. Functional: Globus hystericus (occasional).
1. Onset: Sudden (Foreign body), gradual (all other causes)
2. Nature: Progressive i.e. starting with solids and progressing with semisolids and then liquids or vice
versa causing increasing difficulty with the passage of time (Carcinoma oesophagus, Peritonsillar
abscess, bulbar and pseudobulbar palsy) or non-progressive i.e. not worsening with the passage of
time (All other causes).
3. Site: Note the site where the food seems to stick, where in the mouth or throat (Tonsilitis, Peritonsilar
abscess), behind the cricoid cartilage (Stricture or growth at the upper end of the oesophagus,
Plummer Vinson’s syndrome, neurological or neuromuscular disorder) or behind the xiphisterum
(Stricture or growth of the lower oesophagus, peptic oesophagitis and achlasia). Usually the site of
dysphagia between these upper and lower limits is a good indication of the anatomical level of the
lesion.
4. Type of food causing dysphagia: Solid food (Stricture and growth of the oesophagus, foreign body,
achlasia and peptic oesophagitis) liquid food (Neurological or neuromuscular diseases.) No actual
difficulty in swallowing with either solids or liquids but a feeling of lump in the throat independent of
food intake (Globus hystericus).
5. Painful or Painless: Painful (Tonsilitis, Peritonsilar abscess, Peptic oesophagitis and rarely achlasia),
painless (all other condition).
a) Heartburn i.e. retrosternal burning (Peptic oesophagitis)
b) Sore-throat and fever (Acute Tonsilitis and peritonsilar abscess).
c) Weight loss (Malignancy or any significant obstruction)
d) Recurrent cough and other symptoms of pneumonia (Aspiration pneumonia due to any
oesophageal disease, neurological or neuromuscular disease).
e) Other symptoms of anxiety or depression (Globus hystericus).
f) Nasal regurgitation of fluid, choking and slurred speech (Bulbar or pseudo-bulbar palsy).
g) Attacks of drooping of the eyelids on reading and weakness of the muscles on exercise with
recovery on rest (Myasthenia gravis).
h) Symptoms suggestive of Raynaud’s phenomenon and tightening of the skin of the fingers
(Sclerodema).
7. Progress:
Worsening over a period of few days (Bulbar and pseudobulbar palsy), weeks (Ca of
oesophagus), month (Benign stricture) or intermittent (Myasthenia gravis), no change over the years
(Achlasia and Plummer Vinson’s syndrome).
PAST ILLNESS
Past history of suicidal attempt with corrosives or symptoms of peptic ulcer (Benign stricture due to
corrosives or peptic oesophagitis respectively), any hospital admission and treatment given.

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FAMILY HISTORY
PERSONAL & DRUG HISTORY
History of chronic heavy smoking and/or use of alcohol (Ca of oesophagus and peptic oesophagitis).
Use of antacids or ulcer healing drug (PUD) or drugs for myasthenia gravis.
1. Reflux oesophagitis: Causes dysphagia in some of the chronic patients with peptic ulcer due to
formation of inflammatory benign stricture. Dysphagia is gradual, very slowly progressive with its
site at the lower end of the sternum. There is often a long-standing past history of dyspepsia,
epigastric pain with heart burn, worse on lying and at night. There may be previous history of
treatment with antacis or ulcer healing drugs. The patient may be a heavy smoker and may be
addicted to alcohol.
2. Carcinoma oesophagus: The patient is usually and old person and may be a heavy smoker or
drinker. Dysphagia in such case is usually due to malignant stricture. It is gradual, Progressive with its
site behind the lower, middle or rarely upper sternum. The history is usually of few weeks and is
associated with anorexia and weight loss.
3. Achlasia: The patient is a middle aged person with a long history of many years. Dysphagia is
constant, non progressive and is worse with solids. Its site is at the lower end of the oesophagus. For
the duration of the illness weight loss is not very marked. However, recurrent pneumonias due to
aspiration may be prominent.
4. Globus hystericus: This is not really dysphagia but is a feeling of lump in the throat in hysterical
patients who are usually young females. These symptoms are intermittent and not associated with any
regurgitation. Solid and liquids can be swallowed with out any difficulty although self induced
vomiting can be present. Often previous history of other hysterical symptoms is available.

15
Dyspepsia
Definition:
Upper abdominal pain or discomfort often but not always related to meals is called dyspepsia. It may
or may not be associated with flatulence, heartburn and nausea or vomiting.
CHIEF COMPLAIN:
1. Abdominal pain/discomfort for ............. Days.
COMMON CAUSES:
1. Non-ulcer or functional dyspepsia
2. Gastric and duodenal ulcer
3. Irritable bowel syndrome (IBS)
4. Chronic cholecystitis
5. Chronic pancreatitis
6. Recurrent appendicitis
7. Gastric Carcinoma
1. Age: Young adults (Non-ulcer dyspepsia, duodenal ulcer an hiatus hernia), middle age (Gastric ulcer,
Chronic cholecystitis, Chronic pancreatitis, old age (Gastric Carcinoma).
2. Pain: Ask about
a) Site: Epigastrium or left hypochondrium (Gastric ulcer), Right part of epigastrium (Duodenal
ulcer), Right iliac fossa (Recurrent Appendicitis), right hypochondrium (Chronic cholecystitis),
diffusely over the upper abdomen or the lower abdomen which may spread to the whole abdomen
(Non-ulcer dyspepsia or IBS respctively).
b) Character: Cutting or Burning (PUP & non-ulcer dyspepsia), colicky (Acute attacks of Chronic
cholecystitis and sometimes Recurrent appendicitis), dull (Chronic pancreatitis), fullness or
heaviness (Non-ulcer dyspepsia).
c) Radiation: To right shoulder or the lower angle of the right scapula (Biliary colic in Chronic
cholecystitis), penetrating through to the back (Penetrating duodenal ulcer), from umblicus to the
right iliac fossa (Recurrent appendicitis).
d) Relationship to food: Food causing pain (Gastric ulcer), food relieving pain (Duodenal ulcer), no
definite relation of food (Non-ulcer dyspepsia)
e) Timing of Pain: Pain occurring half an hour after meal (Gastric ulcer), pain one and a half hours
after meals (Duodenal ulcer), pain in the early hours of the morning often waking the patient
(Duodenal ulcer), constant pain in between the meals although increased by meals (Gastric Ca and
penetrating peptic ulcer), no definite relationship of timing of pain to meals (Non-ulcer dyspepsia,
chronic cholecystitis, chronic pancreatitis and recurrent appendicitis).
f) Periodicity: Episodes lasting 7 to 14 days or longer, occurring two to six times a year particularly
in spring and autumn (peptic ulcer), no definite periodicity (all other conditions).
3. Aggravating and Relieving factors:
Worsened by fatty food (Chronic cholecystitis and chronic pancreatitis), spicy food (Peptic
ulcer), running and jolting (Recurrent appendicitis). Relieved by antacid and vomiting (Duodenal
ulcer and sometimes gastric ulcer) or antispasmodic drug (all conditions).
a) Flatulence: belching, bloating, eructations and flatus (Usually non-ulcer dyspepsia and chronic
cholecytitis, sometimes in chronic pancreatitis, recurrent appendicitis and peptic ulcer).
b) Symptoms of depression or anxiety with morning nausea or vomiting and anorexia without any
significant weight loss (Non-ulcer of function dyspepsia).
c) Heartburn (Reflux oesophagitis, sometimes peptic ulcer).
d) Large, bulky, offensive and greasy stools (Chronic pancreatitis).
e) Weight loss (Gastric Carcinoma, Sometimes in peptic ulcer)
f) Diarrhoea alternating with constipation and scanty stools containing mucus (IBS).

16
PAST ILLNESS
Ask about a past history of
a) Attacks of colicky pain in the right hypochondrium (Biliary colic in chronic in chronic
cholecystitis).
b) Haematemesis or melaena (PUD)
c) Similar symptoms in the past (Peptic ulcer and chronic cholecystits).
FAMILY HISTORY
Ask about the history of similar symptoms or death of other family members from a similar disease
(Peptic ulcer or Gastric Carcinoma).
PERSONAL & DRUG HISTORY
Unmarried, separated or tense individual (Non-ulcer dyspepsia or irritable colon), alcoholism
(Chronic pancreatitis and peptic ulcer). History of the use of steroids or non-steroidal anti-
inflammatory drugs (Peptic Ulcer).
1. Non Ulcer or function dyspepsia: The patient is often a tense, unmarried or separated individual
who complains of vague upper abdominal discomfort, flatulence or pain. Pain when present is often
described with sweeping movement of one or both hands. Pain cannot be relieved by simple
measures, is unconvincing or changing from time to time and although it occurs before break-fast, it
does not disturb sleep. Belching, burping and morning nausea may be prominent. When vomiting
occurs patient cannot eat for several hours afterwars. Symptoms are continuous occurring daily over
long periods of time. Associated symptoms of anxiety or depression may be present and there may be
history of previous psychiatric disturbances.
2. Peptic Ulcer: The patient may be young (Duodenal ulcer) or middle-aged individual (Gastric ulcer)
complaining of cutting, or burning pain in the epigastrium or left hypochondrium (gastric ulcer) or
right hypochondrium (duodenal ulcer) which is brought on (gastric ulcer) or relieved by food
(duodenal ulcer) although this association may not be present. Patients with duodenal ulcer may wake
up early in the morning due to pain. Pain is often relieved by antacids or vomiting and worsened by
spicy food, steroids or NSAIDs. Associated symptoms may include nausea, vomiting, retrosternal
burning or water-brash. Haematemesis or malaena may also occur. Symptoms often occur in episodes
lasting 7 to 14 days or longer, two to six times a year with long remissions. Change in the pattern of
symptoms with no relief by food, antacids, or continuous symptoms with associated symptoms of
anorexia, pallor and weight loss in a patient with know gastric ulcer is very suspicious of change to
gastric carcinoma.
3. Chronic cholecystitis: The patient is often but not always a fat , fertile female past her forty
complaining of flatulence with or without biliary colic. Biliary colic presents as pain in the right
hypochondrium or epigastrium which may radiate to right shoulder or scapula. Pain is very severe,
coming in attacks lasting for minutes to hours and associated with vomiting, shivering and sweating
and relieved by strong analgesics only. There may be history of jaundice, clay coloured stools and
dark urine after such an attack. These symptoms are often worsened by fatty or fried meals.

17
Diarrhoea
DEFINITION:
It may be defined as increase in the frequency or fluidity or both of the stools.
(Passage of loss watery stool more than 3 times in a day).
CHIEF COMPLAIN:
1. Passage of stool for .............times.
COMMON CAUSES:
1. Infective causes:
a) Protozoal e.g. Amoebiasis, Giardiasis
b) Bacterial e.g. Bacillary dysentery. Food poisoning due to salmonella, Clostridia and E. Coli,
Cholera, Intestinal TB.
c) Viral e.g. Rota virus, Enteroviruses.
2. Irritable Bowel Syndrome.
3. Inflammatory bowel disease e.g. Ulcerative colitis and Crohn’s Disease.
4. Malabsorption syndrames e.g. Coeliac disease, tropical sprue, Lactase deficiency, chronic
pancreatitis.
5. Tumours: Villous adenoma, colonic carcinoma and carcinoid tumours.
6. Drugs e.g Antibiotics, Antacids containing Mg. Laxatives, Antihypertensive agents and
cholinergic drugs
7. Miscellaneous e.g Diverticulitis, Traveller’s diarrhoea, sometimes roundworm, tapeworm and
hookworm infestations, psychogenic diarrhoea.
1. Age at onset: Adolescence or early adult life (TB, IBS, Ulcerative colitis and Crohn’s disease), middle
or old age (Carcinoma colon, diverticulitis and pancreatitic disease) any age (Most infectious, drug
induced and endocrine disorders).
2. Duration and course: Acute onset with a course of few days (Viral gastroenteritis, bacillary dysentery,
amoebic dysentery, food poisoning due to salmonella, clostridia, E. Coli, Cholera, Traveller’s diarrhoea
and psychogenic diarrhoea due to stress), acute onset with long course (Ulcerative colitis, Crohn’s
disease, diverticulitis and cathartic abuse), gradual onset with long course and periods of freedom
(Diarrhoea due to malabsorption, endocrine diseases and irritable bowel syndrome).
3. Pattern of diarrhoea: Continuous (Ulcerative colitis, Crohn’s disease, Laxative abuse and intestinal
fistulas), Intermittent (Psychogenic diarrhoea, malabsorptiom syndrome and diverticulitis) or diarrhoea
alternating with constipation (Intestinal Tuberculosis, irritable bowel syndrome, excessive use of
laxatives, Carcinoma of the colon and diverticulosis).
4. Frequency of the stools: Ask about the number of motions passed since the onset of diarrhoea or in
chronic case in 24 hours. Although this information does not help in diagnosis, it is important to judge
the need of urgency for treatment and to check the response to the treatment.
5. Character of the stools:
a) Quantity and consistency: Small quantity of solid or semisolid stools (IBS and cathartic abuse),
Copious amounts of watery stools (Viral gastroenteritis, Cholera, villous adenoma and often in
diarrhoea due to endocrine disorders), semisolid stools of variable quantity (Amoebic and
bacillary dysentery, ulcerative colitis, Crohn’s disease), bulky, watery and greasy stools
(Malabsorption syndrome).
b) Presence of mucus, pus or blood: Stools containing mucus without pus or blood (Irritable
colon and chronic amoebiasis), mucus and blood (Amoebic dysentery, ulcerative colitis, Crohn’s
disease and pseudomembranous colitis), blood and pus (Bacillary dysentery, sometimes
ulcerative colitis and Crohn’s disease), Soft non-fatty stools (Gastric diarrhoea). Bulky fatty
offensive stools which are difficult to flush (Malabsorption syndrome).

18
6. Diurnal variations and relationship to meals: Occurring primarily in the morning and after meals
(Gastric disorder, psychogenic diarrhoea, ulcerative colitis and Crohn’s disease), no diurnal variations
(Infectious disease), nocturnal (Characteristic of diabetic neuropathy but not specific for it because any
severe diabetic can occur at night). Nocturnal diarrhoea is usually due to an organic causes.
a) Tenesmus (Any inflammatory disease of the bowel with anorectal involvement e.g. Amoebic and
bacillary dysentery, ulcerative colitis, Chohn’s disease and anorectal carcinoma).
b) Abdominal cramps relieved by defecation (Small intestinal disease), abdominal cramps persisting
after defecation (Large intestinal disease).
c) Fever (viral gastroenteritis, Bacillary dysentery, Tuberculous colitis, Ulcerative colitis, Crohn’s
disease and psedomembranous colitis).
d) Vomiting (Viral gastroenteritis, Addison’s disease, rarely drug induced diarrhoea, ulcerative
colitis and Crohn’s).
e) Weight loss: In the presence of normal appetite (Hyperthyroidism, Malabsorption syndrome),
preceding diarrhoea (Carcinoma colon or other malignancy, Tuberculosis, diabetes mellitus,
hyperthyroidism and malabsorption), No weight loss despite long-standing diarrhoea (Irritable
colon and psychogenic diarrhoea).
f) Joint Pains (Ulcerative Colitis, Crohn’s disease and reactive arthritis).
g) Painful red eyes (Ulcerative colitis, Crohn’s disease).
h) Skin rash (Ulcerative colitis, Crohn’s disease and Dermatitis herpetiformis).
i) Polyuria, Polydipsia and impotence (Diabetic autonomic neuropathy).
j) Intolerance to heat, weight loss despite good appetite and prominence of eyes (Hyperthyroidism).
k) Darkening of the skin (Addison’s disease).
PAST ILLNESS
Particularly note a past history of
a) Similar symptoms (Ulcerative colitis and Crohn’s disease)
b) Attacks of diarrhoea at the time of stress (Psychogenic diarrhoea)
c) Skin rash (Dermatitis herpetiformis)
d) Diabetes mellitus.
e) Operations on the stomach or intestines.
FAMILY HISTORY
Similar symptoms occurring in other family members partaking the same food (Food
poisoning), Rarely ulcerative colitis and Crohn’s disease may run in the families.
PERSONAL HISTORY
Any intolerance to wheat and wheat products (Coeliac disease) or milk products (Lactase deficiency).
Also none any allergies.
DRUG HISTORY
Enquire about the use of
a) Laxatives for habitual constipation (Laxative abuse).
b) Broad spectrum antibiotics especially clindamycin and linconycin (Pseu-membranous colitis),
Ampicillin, amoxycillin and tetracyclines (Diarrhoea due to irritant effect). Neomycin
(Malabsorption). Also note the drugs being used for treatment of diarrhoea.

19
1. Amoebic dysentery: This is the most common causes of diarrhoea in endemic areas. In adult stage it
causes frequent semisolid to loose stools with blood and mucus. Often there is tenesmus and griping
abdominal pain. In chronic stage there are occasional semisolid motions with mucus in the stools and
associated pain in right iliac fossa. Rarely there may be constipation. If untreated pain in the right
hypochondrium and fever with rigors may occur due to amoebic hepatitis or amoebic liver abscess.
There is a good response to anti-amoebic drugs (e.g Metronidazole and tinidazole).
2. Bacillary dysentery: Patient presents with sudden onset of fever, diarrhoea and pain in the lower
abdomen mainly in the left iliac fossa. Stools are mixed with pus and blood and may be scanty.
THere is usually a good response to antibiotics.
3. Non-specific diarrhoea: It is a self-limiting diarrhoea usually caused by viral infections or the
enterotoxins produced by shigella, salmonella, vibrio or clostridia causing viral gastroenteritis or
food poisioning in patients partaking the same food. There is often painless watery diarrhoea with
very frequent stools. There may be associated fever and vomiting. Diarrhoea responds to
symptomatic treatment.
4. Irritable bowel syndrome: (Spastic or mucus colitis);
The patients are often tense, irritable individuals often with symptoms of anxiety complaining of
passage of scanty, semisolid stools containing mucus alternating with constipation. There may be
flatulence and discomfort in the epigastrium (Non-ulcer dyspepsia). Despite symptoms of anorexia
and long history there is no weight loss.
5. Ulcerative colitis: The disease may start acutely with severe diarrhoea, fever, tensmus, blood, mucus
and pus in the stools. Occasionally, There may be frequent semi-solid motions with tenesmus. These
features may be associated with pain and swelling of the joints. Remissions and exacerbations are
common. Severe distension of the abdomen in an acute attack indicates toxic megacolon and needs
emergency treatment. Diarrhoea responds to steroids or sulpha-salazine.
6. Crohn’s Disease: This is a granulomatous disease of the intestine which often presents acutely with
fever, pain in the right iliac fossa and diarrhoea containing mucus, pus and blood and is associated
with tenesmus. Although remissions and exacerbation do occur with the passage of time
complications result in intestinal perforation and fistulas and patient with chronic disease often has
history of corrective operations. As in ulcerative colitis there may be associated skin, eye or joint
involvement.
7. Malabsorption syndrome: Diarrhoea is often continuous with the passage of painless, bulky,
offensive and greasy stools which are difficult to flush. There is often flatulence, abdominal
distension and weight loss despite good appetite. Associated symptoms may include bone pains
(Osteomalacia), skin pigmentation (Pellegra), Pallor (Iron, folic acid and vitamin B12 deficiency
anaemia), symptoms indicating the underlying cause may include polyuria and polydipsia (Diabetic
diarrhoea), poly-arthritis (Crohn’s disease), jaundice (Biliary cirrhosis), intolerance to the products of
wheat (Coeliac disease), intolerance to milk or milk products (Lactase deficiency or lactose
intolerance), itchy eruption preceding diarrhoea (Dermatitis herpetiformis) or cough and
expectoration of foul smelling sputum since childhood (Mucoviscidosis).
8. Nervous diarrhoea: Diarrhoea consists of watery stools with hardly any faecal material occurring in
tense, neurotic individuals at the time of stress, e.g. examinations and interviews. Diarrhoea is
usually self limiting.

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Constipation
Definition:
Constipation is the passage of small (Quantity less than 50 Gms/day), dry and infrequent stools.
CHIEF COMPLAIN:
1. Difficulty to passage of stools for .............Days.
COMMON CAUSES:
1. Physical inactivity (Due to paralysis or chronic illness)
2. Low roughage diet
3. Drug induced e.g. Diuretics, anti-depressants, anti-diarrhoeals, antacids (Aluminum
containing), Opiates and laxative abuse.
4. Psychiatric problems e.g. depression and anxiety.
5. Irritable bowel syndrome.
6. Systemic disorders e.g. Hypothyroidism, Diabetes mellitus and pregnancy.
7. Inflammatory or mechanical narrowing of the bowel e.g. Chronic amoebiasis, ulcerative
colitis, Crohn’s disease, diverticulitis and tumors of the rectum and colon.
1. Usual bowel habit: It is important to know at the outside the usual bowel habit of the patient.
Complaints of constipation even with the passage of one to two stools a day with chronic use
of purgatives usually indicates poor bowel habits. Many patients on the other hand have one
bowel action every other day and are happy about it. Note the frequency of bowel action, its
quantity and consistency.
2. Duration: Long standing (Improper eating habits, poor bowel habits, inadequate fluid intake,
physical inactivity, medications and laxative abuse, depression, Irritable bowel syndrome or a
combination of the factors) or recent (Tumours of the rectum or colon, Crohn’s disease,
ulcerative colitis or intestinal obstruction). Recent constipation is more significant than
chronic constipation.
3. Severity: After how many days the stools are passed? This is only significant in planning the
treatment but rarely helps in the diagnosis of the underlying causes.
4. Alternation with diarrhoea: Enquire whether it alternates with diarrhoea (Irritable bowel
syndrome, chronic amoebiasis, Crohn’s disease, diverticulitis and laxative abuse).
a) Blood in the stools i.e. Haematochezia (Ulcerative colitis, Crohn’s disease,
haemorrhoids, cancer of the rectum or colon.
b) Vomiting (Intestinal obstruction)
c) Intolerance to cold, weight gain and hoarseness of voice (Hypothyroidism)
d) Recent stroke, operation, heart attack or any chronic illness (Physical inactivity or
anorexia causing constipation).
e) Symptoms suggestive of depression or anxiety.
PAST ILLNESS
Of constipation (Laxative abuse) or abdominal surgery (Intestinal obstruction).
FAMILY HISTORY
Nothing contributory
PERSONAL HISTORY

21
DRUG HISTORY
Enquire about the use of laxatives or drugs which can causes constipation (Anti-diarrhoeals,
Aluminum containing antacid, anti-depressants, diuretics and haematinics).
1. Irritable bowel syndrome (See under ‘Diarrhoea’)
2. Amoebiasis (See under ‘Diarrhoea’)
3. Myxoedema :- (See under ‘Generalized swelling’)
4. Ulcerative colitis, Crohn’s disease (See under ‘Diarrhoea’)

22
Jaundice
Definition
It is the yellow discoloration of mucus membranes and skin due to raised serum bilirubin level. It is
usually evident in the sclera when serum bilirubin is equal to or more than 2mg% (20µgm%).
CHIEF COMPLAIN:
1...............................................................................................................Days
COMMON CAUSES:
1) Haemolytic Anaemia (Pre-hepatic Jaundice)
a) Auto-immune Haemohytic anaemia.
b) Thalassaemia
c) Glocose-6-Phosphate dehydrogease deficiency
d) Blood transfusion reaction
2) Hepatic
a) Viral Hepatitis
b) Toxic Hepatitis (Toxic drugs or chemicals)
c) Infiltrative disease (Cirrhosis liver, Wilson’s disease, Haemochoromatosis)
d) Congenital hyperbilirubinaemias (Gilbert’s disease, Dubin Johnson’s Syndrome, Rotor’s
syndrome)
3) Post Hepatic (Obstructive)
a) Choledocholithiasis
b) Cholangitis and cholestasis
c) Malignancies: Carcinoma head of the pancreas, Carcinoma Ampulla of vater, carcinoma
common bile duct.
1. Duration: Longstanding for years (Familial Hyperbilirubinaemias), recent (Infection, toxi
Hepatitis, haemolytic jaundice and obstructive Jaundice).
2. Onset: Sudden (Haemolytic, Stone common bile duct), Gradual (Infective, drug induced
hepatitis).
3. Color of stools: Normal (Haemolytic or Heaptocellular jaundice), Clay colored (Obstructive
Jaundice).
4. Color of Urine: Dark coloured (all types of jaundice). Indicates intensity of jaundice but does
not help in differential diagnosis.
a) Pain right upper abdomen: dull (Viral and drug induced Hepatitis), Colicky
(Choledocholitiasis).
b) Heaviness left Hypochondrium (Cirrhosis liver, haemolytic jaundic, rarely viral and toxic
Hepatitis), occurs because of enlarged spleen.
c) Fever: preceding jaundice, usually sub-siding with the onset of jaundice (viral hepatitis),
intermittent fever with rigors at the onset of jaundice (Haemolytic Jaundice).
d) Appetite: Poor (Viral and drug induced Hepatitis) tent (Haemolytic crisis, stone common
bile duct, carcinoma Ampulla of vater), progressive (Carcinoma head of the pancreas).
PAST ILLNESS
1. Injection or blood transfusions (HBV & HCV)
2. Contract with a jaundice patient (Hepatitis A and E)
3. Alcohol intake (Alcohol Hepatitis)
4. Use of Drugs e.g. Antituberculous, phenothiazines, Methyl-dopa, Erythocin estolate or MAO inhitors
(Drug induced Hepatitis).

23
FAMILY HISTORY
History of contact with a case of jaundice (Viral Hepatitis), history of pallor with jaundic (Familial
Haemolytic Anaemias), asymptomatic jaundice (Benign familial hyperbilirubinaemias).
PERSONAL HISTORY
DRUG HISTORY
1. Viral hepatitis: Often (but not always) there is history of similar case in the community (Hepatitis A
and E), or needle prick, injections or blood transfusion, some months before jaundice (Hepatitis B and
C). There is often a period of flu-like symptoms with fever before jaundice occurs. Fever subsides at
the onset of jaundice. There is usually severe anorexia and nausea which may be associated with
vomiting. There is constant dull pain in right Hypochondrium because of enlarged liver. Urine colour
is dark but stools are of normal colour. Without any complications the jaundice often gradually
subsides over a period of weeks with increase in appetite and decrease in pain, nausea and vomiting.
2. Obstructive jaundice: Usually occurs in middle aged fertile fat females with previous history of
colicky upper abdominal pain and jaundice, in such case the usually cause is a stone in the common
bile duct. Progressive jaundice in an old person with pain upper abdomen radiating through to back
often indicates carcinoma head of pancreas. In obstructive jaundice there may be clay coloured stools
and itching may be troublesome. Fever with rigors in such a case indicates cholangitis. Longstanding
case of obstructive jaundice may develop diarrhoea due to malabsorption.
3. Drug Induced jaundice: Often such a patient has been taking drugs for tuberculosis (INH,
Rifampicin, Pyrazinamide or Thiacentazone), Antihypertensives (Methyldopa), Antidepressants
(Tricclic drugs and Monomine oxidase inhibitors) or had anesthesia (Halothane). Usually the
symptoms are similar to viral Hepatitis and jaundice gradually subsides on withdrawing the offending
drug.
4. Haemolytic Jaundice: Jaundice is often preceded by fever with rigors indicating haemolytic crisis.
Jaundice is sudden in onset and is associated with pallor of the skin. There may be history of episodes
of similar jaundice in the past which coluld have been precipitated by drugs (Glucose-6-Phosphate-
dehydrogenase deficiency). Family history may be positive (Thalassaemias, sickle cell disease),
hereditary spherocystosis and G-6-PD deficiency).

24
Abdominal Distension
CHIEF COMPLAIN:
1. Passage of Bloody vomiting for .............times.
2. Passage of Black tarry stools for .............Days.
COMMON CAUSES: (6-F)
1. Fat- Obesity
2. Fluid- Ascites, tumours (especially ovarian)
3. Faeces- Sub-acute obstruction, Constipation
4. Fetus/Pregnancy- Check date of the last Menstrual period
5. Flatus- Pseudo-Obstruction, obstruction
6. Functional-Bloating, often associated with irritable bowel syndrome.
1. Onset: Sudden (Acute intestinal obstruction), gradual (Pregnancy, obesity, ascites and ovarian
cyst).
2. Progression to and from other sites:
a. Localized only to the abdomen (Pg, Intestinal obstruction, TB, Malignant ascites and ovarian
cyst).
b. Starting from the abdomen and progressing to the legs or feet (Ascites due to Cirrhosis of liver).
c. Starting from the feet and legs and progressing to the abdomen (CCF)
d. Starting from the lower eyelids and face and progressing to abdomen and feet (Ascites due to
Nephrotic syndrome).
3. Presence or absence of pain: Ask whether the abdominal distension is painful (intestinal
obstruction
and malignant infiltration), or painless (obesity, Pg, Ovarian cyst and transudative ascities due to
Cirrhosis liver, CCF and NS).
4. Other associated symptoms:
a. Amenorrhea: (Pg, Ovarian cyst and sometimes with TB ascites, Cirrhosis liver and NS).
b. Breathlessness on exertion, orthopnoea, paroxysmal nocturnal dyspnoea and pain in the right
hypochondrium (CCF).
c. Colicky abdominal pain, absolute constipation and vomiting (Intestinal obstruction)
d. Fever (TB ascites and peritonitis due to rupture of a viscus rarely due to malignant ascites)
e. Weight loss and change in the bowl habits (Malignant ascites due to GIT malignancy).
f. Discomfort or mass in the left hypochondrium (Splenomegaly due to cirrhosis of liver)
PAST HISTORY
1. Jaundice (cirrhosis of liver)
2. Fever (Peritonitis due to ruptured typhoid ulcer or appendix and spontaneous bacterial peritonitis)
3. Operation for some malignant disease (Malignant ascites).
4. Dyspepsia (Perforated peptic ulcer)
5. Abdominal operation or hernia (Intestinal obstruction)
6. Rheumatic fever, HTN, IHD (Ascites due to CCF)
FAMILY HISTORY
1. HTN, IHD (Ascites due to CCF)
2. TB (TB ascites).
PERSONAL HISTORY
DRUG HISTORY
Enquire about the use of: Diuretics (All oedematous states), Digoxin (CCF),
Anti-TB drugs (TB ascites), Kushtas and other nephrotoxic drug (NS).

25
1. Pregnancy: The patient is often a young female of child bearing age who complains of gradual,
painless abdominal distension starting from the lower abdomen. Associated symptoms include
amenorrhea, morning sickness and in late stage fetal movements. Although swelling of the feet may
sometimes occur, this is usually on walking, standing or sitting with the legs hanging.
2. Obesity: The complains are of gradual, painless distension of the abdomen as a part of generalized
weight gain due to fat deposition which has no effect of posture or pressure.
3. Tuberculous Ascites: Patient often complains of gradual painful distension of the abdomen without
any swelling of the feet or face. There may be a history of fever, night sweating, cough, anorexia and
weight loss. There may also be a past history of diarrhoea alternating with constipation and patient
may be taking anti-TB drugs.
Family history for TB may be positive.
4. Intestinal obstruction/Paralytic ileus: There is history of sudden painful distension of the abdomen
with vomiting and absolute constipation without any swelling of the feet or face. The pain is colicky
in intestinal obstruction and dull in paralytic ileus. There may be history of fever (Ruptured appendix
or perforated peptic ulcer) or dyspepsia (Perforated peptic ulcer). There may be past history of
abdominal operation (Adhesions causing intestinal obstruction).
5. Ascites due to cirrhosis liver, CCF and NS:

26
Cough and Expectoration
Common causes:
1. Upper respiratorytract infection
a) Pharyngitis
b) Tonsillitis
c) Sinusitis
d) Tracheitis
2. Lowerrespiratory tract infection
a) Acute and chronic bronchitis
b) Pneumonia
c) Lung abscess
d) Bronchiectasis
e) Pulmonary TB
3. Bronchialasthma and chronic Bronchitis
4. Pulmonary fibrosis including pneumonia
5. Malignant disease e.g. Carcinoma bronchus and carcinomallarynx.
6. Cardiac disease e.g.Pulmonary oedema.
7. Neurologicaldiseasee.g. Recurrentlaryngealnerve palsy.
1. Duration:- Long standing (Chronic bronchitis, bronchial asthma, chronic sinusis,
Bronchiectasis, pulmonary fibrosis), recent onset (Acute tonsillitis and pharyngitis,
pneumonia, acute bronchitis and tracheobronchitis, acute pulmonary oedema and
recurrent laryngeal nerve palsy).
2. Onset: Sudden (Acute bronchitis, acute pulmonary oedema and foreign body), in
attacks (Bronchial asthma, pulmonary oedema), gradual (pneumonia, chronic sinusis
and bronchitis, pulmonary TB, Lung abscess and bronchiectasis) .
3. Dry or Productive: Dry cough (In early stages of most of the respiratory infections,
dry pleurisy, Pulmonary fibrosis, recurrent laryngeal nerve palsy), productive (in all
established respiratory infections and pulmonary oedema).
4. Sputum: If the cough is productive ask about:
a) Color: Froth white, sometimes mixed with blood (Pulmonary oedema), rusty
(Resolution stage of lobar pneumonia), yellowish (most pyogenic infections),
greenish (Pseudomonas infection usually in lung abscess and bronchiectasis),
brick red (Kelbsiella infections), anchovy sauce (Ruptured amoebic liver abscess),
black (coal miner’s lung) or containing blood i.e. haemoptysis (Pulmonary
tuberculosis, Lung abscess, Bronchiectasis and bronchogenic carcinoma).
b) Odour: Foul smelling (Anaerobic or mixed infections e.g. lung abscess and
bronchiectasis).
c) Quantity: Ask about rough estimate of quantity of sputum expectorated in 24
hours e.g. how many cupful: Scanty (Bronchial asthma, pharyngitis, acute

27
bronchitis, resolution stage of pneumonia and pulmonary oedema), large
(Bronchiectasis and lung abscess).
d) Character of sputum: Frothy (Pulmonary oedema), mucoid, difficult to
expectorate with treat formation (Bronchial asthma) mucopurulent (Acute
exacerbations of bronchial asthma and chronic bronchitis), Purulent
(bronchiectasis and lung abscess).
e) Relation to posture and behavior on collection: More sputum production when
lying on one side (Disease of the opposite lung), more sputum production when
learning forward (Disease of the lung base e.g. lung abscess and bronchiectasis),
more sputum production on waking (Lung abscess and bronchiectasis) formation
of three layers on collection of sputum in a container (Lung abscess and
bronchiectasis). These layers are from above downward: foam, fluid and sediment.
f) Effect of expectoration on breathing: In most of the cases breathing is easier
after expectoration but this is more remarkable in bronchial asthma.
5. Diurnal and day to day variation of cough:- Cough worse at night (Bronchial
asthma, Pulmonary oedema and rarely chronic bronchitis) or on first day of the week
on duty after the weekend (Bagassosis), no definite diurnal variation (Most other
causes of cough).
6. Character of cough: Note the character of cough when the patient is requested to
cough: brassy (tracheal compression), bovine (Recurrent laryngeal nerve palsy),
barking (Tracheobronchitis), whooping (Pertusis).
7. Associated symptoms:- Ask about:
a) Wheeze (Bronchial asthma, acute pulmonary oedema, many cases of
bronchitis).
b) Attacks of breathlessness (Bronchial asthma and acute pulmonary oedema).
c) Breathlessness on exertion, paroxysmal nocturnal dyspnoea and orthopnoea
(Left venticular failure).
d) Pleuritic chest pain (Pleurisy due to lobar pneumonia and pulmonary infarction).
e) Fever (Tuberculosis and all acute respiratory infections).
f) Postnasal discharge (Acute and chronic sinusitis).
g) Weight loss (Bronchogenic carcinoma, all chronic respiratory infections
particularly pulmonary tuberculosis, lung abscess and bronchiectasis).
8. Aggravating factors: Dust or fumes (Bronchial asthma and to some extent chronic
bronchitis), lying on the unaffected side (all unilateral respiratory diseases), exercise
(Atopic asthma), cold drinks and bitter food (most of the respiratory infections), Beta
receptor blocking drugs (bronchial asthma and chronic bronchitis).
9. Relieving factors:- Bronchodialators e.g. aminophylline and salbutamol (Bronchial
asthma and to same extent acute and chronic bronchitis and pulmonary oedema),
Prednisolone (Bronchial asthma to some extent acute or chronic bronchitis), Diureties
and digoxin (Heart failure).

28
10.Course: Attacks with relief in between (Bronchial asthma), progressive worsening
unless treated (Pulmonary fibrosis and heart failure), usually static with acute
exacerbation off and on (Chronic sinusitis, tonsillitis and bronchitis).
PAST HISTORY
Ask about the past history of:
1. Measles or whooping cough in childhood (Bronchiectasis).
2. Any past history of pulmonary TB and any treatment taken (Relapse or bronchiectasis
as a complication).
3. Rheumatic fever, hypertension, history suggestive of angina pectoris or heart attack
(Acute pulmonary oedema due to these diseases).
4. All previous hospital admissions, investigations done, given to the patient regarding
prognosis.
FAMILY HISTORY
Ask about:
1. History of similar symptoms in other family members (Pulmonary tuberculosis,
sometimes bronchial asthma).
2. Consanguinity of parents (Mucoviscidosis, Kartagenar’s syndrome).
PERSONAL HISTORY:
1. Smoking: If the patient is a smoker, ask about smoking habits, number of cigarettes
smoked daily and bronchogenic carcinoma).
2. Alleries and history of hay fever and eczama (Atopic asthma).
3. Occupation: Ask about occupation, present and past and duration of exposure e.g. work
coal, silica and asbestors (Pneumoconiosis), work in sugar industry (Bagassosis), work
on farms (Farmer lung).
4. Hobbies: Pigeons, parrots and budgeriger fanciers (Extrinsic allergic alveolitis as a
causes of pulmonary fibrosis).

29
1. Chronic sinusitis: Patient often gives history of long standing postnasal discharge with
recurrent attacks of cough productive of variable quantity of muco-purulent sputum and
headache. Headache is usually frontal and often has a characteristic pattern (See
headache due to sinusitis). Fever may occur during acute exacerbations.
2. Chronic bronchitis: The patient who is often a smoker, complains of cough
productive of sputum for more than two years lasting for more than three months in
one year. Cough is productive of copious amounts of mucoid sputum which may
become mucopurulent during acute exacerbations. There is often associated
breathlessness, wheeze and sometimes fever. Patient often responds to bronchodilators,
antibiotics and to some extent steroids. Gradually the symptoms worsen leading to
features of Cor-Pulmonale.
3. Bronchial asthma: The patient may be a child or and adult. In children there is history
of cough, breathlessness and wheeze, episodic in nature, with relief in between the
attacks and aggravated by exercise. There could be history suggestive of allergic
rhinitis, eczema or nasal polyps in these children. Most of these children are cured of
the disease by school leaving age. In adults the symptoms are more or less continuous
and are increased during acute exacerbations. There is cough, breathlessness, wheeze
and tightness of the chest which could be aggravated by dust, cold, rice and sometimes
by NSAIDs. In asthma of childhood and adults, the cough is often dry but can be
productive of scanty amounts of thick, tenacious sputum which partially relieves the
symptoms. Nocturnal attacks are common. There is usually a good response to
bronchodilators and steroids.
4. Pulmonary TB: Usually there is history of cough which may be dry initially, later on
becoming productive of muco-purulent sputum and sometimes haemoptysis which
could be massive and life-threatening. There is often a low grade fever with evening
rise of temperature, sweating, anorexia and weigh loss. Sever disease can lead to
breathlessness. The patients are often poor and living in overcrowded conditions. There
could be history of another family member or work mate having had the treatment for
TB or having symptoms similar to that of the patient.
5. Lobar pneumonia: Usually there is history of fever, dry cough and pleuritic chest
pain with breathlessness. During resolution of pneumonia there is rusty sputum in
pneumococcal pneumonia, yellowish sputum in most pyogenic infections and brick red
sputum in klebsiella pneumonia. Uncomplicated pneumonia usually lasts for one to two
weeks when untreated.
6. Acute pulmonary oedema: In a patient with past history of hypertension, ischaemia or
valvular heart disease, then is sudden breathlessness, cough productive of moderate
amounts of frothy sputum which may be blood stained. The attacks are often nocturnal
usually waking the patient (as well as the doctor!) from sleep. There may be also
history of exertional dyspnea and orthopnoea. Patients often respond to diuretics and
sometimes to bronchodilators. The condition is due to acute Left ventricular failure and
also called cardiac asthma because it may also be associated with wheeze.

30
7. Bronchectasis: There is a history of cough productive of large amounts of purulent,
foul smelling sputum more on waking than during the rest of the day. There may be
haemoptysis, fever, breathlessness and variation of sputum production with posture.
Sputum on standing forms three layers i.e. foam, fluid and sediment from above
downward. There could be a past history of whooping cough or measles in childhood
or treatment of pulmonery TB.
8. Lung abscess: The symptoms are usually similar to bronchietasis except that the
duration is shorter and there is swinging fever with rigors and more marked weight
loss.
9. Pulmonary fibrosis: These patients may have a history of occupational exposure to
industrial dust (Pneumocomiosis), long contact with birds (Bird fanciers lung) although
the case may be unknown (Cryptogenic fibrosing alveolitis). Patient presents with long
history of dry cough and progressively increasing breathlessness which may worsen
during intercurrnt infections. There is little or no response to steroids. Ultimately
features of cor pulmonale develop in these patients.
10.Bronchogenic carcinoma: The patient is often an cold man who has been a heavy
smoker. There is history of cough, breathlessness, anorexia and weight loss. Cough
may be dry but is often productive of sputum which may be blood stained. Sometimes
the presentation is with features of pneumonia which fails to resolve. If recurrent
laryngeal nerve is involved, there is hoarseness of voice and a bovine nature of cough.

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Haemoptysis
Definition: Passage of blood in the sputum is called haemoptysis. The amount of blood may vary between
streaks to massive bleeding.
Common Causes:
1. Respiratory causes: PTB, Bronchiectasis, Lung abscess, Bronchogenic adenoma & Carcinoma and
pulmonary infarction.
2. Cardiac: Mitral stenosis.
3. Haematologic: Thrombocytopenia and clotting disorders.
1. Duration: Short (Pulmonary infarction and mitral stenosis), Long (Pulmonary
Tuberculosis, Bronchiectasis, lung abscess and rarely bronchogenic carcinoma).
However the duration to a large extent depends upon when the patient decides to see
the doctor.
2. Quantity: Scanty i.e. streaks of blood in the sputum (Acute pharyngitis and tonsillitis),
moderate (Pulmonary tuberculosis, bronchogenic carcinoma, sometimes bronchiectasis
and lung abscess).Again, quantity of blood may vary from time to time in the same
patient.
3. Relationshipto posture: While lying on one or the other side (Bronchiectasis and
lung abscess).
4. AssociatedSymptoms:
a) Foul smelling sputum (Bronchiectasis and lung abscess)
b) Fever (Pulmonary tuberculosis, tonsillitis, pharyngitis, off and on in bronchiectasis
and lung abscess).
c) Chest pain (Pulmonary infarction, rarely in pulmonary tuberculosis, bronchiectasis
and lung abscess dueto superadded infection).
d) Breathlessness on exertion, orthopnoea and paroxysmal noctumal dyspnoeawith or
without swelling feet and pain right hypochondrium (Mitral stenosis).
e) Severe anorexia and weight loss (Bronchogenic carcinoma and pulmonary
tuberculosis).
f) Bleeding in the skin and from other sites (Bleeding diathesis).
PAST HISTORY:
Ask about a past history of:-
Measles or whooping cough (Bronchiectasis), unconsciousness or anesthesia (lung
abscess), Operation causing bed rest (pulmonary infarction). Also enquire about any
incomplete or irregular anti-tuberculous therapy.
FAMILY HISTORY:
About any other family member having Pulmonary TB or bleeding disorder and about size of
the family with particular reference to overcrowding in rooms.

32
PERSONAL HISTORY:
About smoking (Bronchogenic Carcinoma) and Diabetes mellitus (More prone to pulmonary
tuberculosis, Lung abscess and bronchiectasis).
DRUG HISTORY
Same to “Cough and Expectoration.”

33
Breathlessness
Common Causes of breathlessness:
2. Acute severe bronchial asthma
3. Acute exacerbation of COPD
4. Acute LVF due to any cause
5. Acute pulmonary oedema
6. Pneumothorax
7. Pneumonia
8. Pulmonary embolus
9. Chronic congestive cardiac failure
10. CCF
11. Metabolic acidosis due to renal failure & Diabetic Ketoacidosis
12. GAD: Hyperventilation
1. Duration:
Short : Pulmonary embolism, Pneumothorax, Pneumonia, Bronchial asthma, Acute Pulmonary
Oedema and Pleural effusion.
Long : CCF, Chronic Bronchial asthma, Pulmonary fibrosis.
2. Onset :
Sudden : Pulmonary embolism, Pneumothorax.
Gradual : CCF, Bronchial asthma, Chronic Bronchitis, Pulmonary fibrosis.
In attacks : Atopic asthma and hyperventilation.
3. Severity: Severity of breathlessness can be decribed in grades according to the degree of exertion
which causes breathlessness. Ask whether breathlessness occurs on severe exertion e.g. running up
two flights of stairs (Grade-I) or on moderate exertion e.g. walking normally up two flights of stairs
(Grade-IIA), or On mild exertion e.g. walking slowly up one flight of stairs (Grade IIB) or on
minimal exertion e.g. walking from room to room (Grade III) or it is present even at rest (Grade IV).
This grading is helpful in recording progress of symptoms and indicating the degree of disability.
4. Reliving factors: Diuretics (CCF), Bronchodilator (Bronchial Asthma and Some extent Chronic
bronchitis), Coughing up thick scanty sputum (Bronchial asthma), sitting up in bed or use of extra
pillow (Heart failure).
5. Aggravating factors: Dust, fumes and cold weather (Bronchial asthma), Night time (Bronchial
asthma), lying flat (CCF).
a. Cough: With occasional thick scanty sputum (Bronchial asthma), with mucoid or mucopurulent
sputum (Chronic bronchitis), with frothy sputum, sometimes blood stained (acute Pulmonary
edema).
b. Chest pain: Sudden pain followed by breathlessness (Pneumothorax and pulmonary embolism)
c. Wheeze: (Bronchial asthma, chronic bronchitis and sometimes acute pulmonary oedema)
d. Sneezing: skin lesions and allergies (Bronchial asthma-atopic variety).
e. Fever: (Pneumonia or empyma thoracis)
f. Orthopnoea, paroxysmal nocturnal dyspnoea, swelling feet and pain right hypochondrium (CCF).
g. Attacks of fits following numbness around the mouth with other symptoms of anxiety
(Hyperventilation).
h. Symptoms of chronic renal failure as the underlying causes of breathlessness.

34
PAST HISTORY:
1. Symptoms suggestive of rheumatic fever (CCF due to Rheumatic heart disease) HTN or angina
and/or MI as the case of CCF.
2. Any previous hospital admission or cardiac operation.
FAMILY HISTORY:
1. Of Bronchial asthma.
2. Family background in case of hyperventilation due to anxiety or hysteria.
PERSONAL HISTORY:
1. Of smoking (Chronic bronchitis)
2. Working in cotton or sugar-cane industry (Lung fibrosis due to Bagassosis) or in mines
(Pneumoconiosis)
3. Keeping pets e.g. Parrots, Pigeon etc (Lung fibrosis due to pigeon fancier;’s lung or Budgregar’s
lung).
1. Bronchial Asthma: The History of attacks of sudden breathlessness which is worse at night and is
aggravated by cold, dust, fumes and in children by exercise. Breathlessness is associated with wheeze
and cough. Cough is productive of scanty amounts of thick, tenacious sputum which is difficult to
expectorate. There may be an associated feeling of generalized chest tightness. Patient may also have
symptoms of skin allergies or allergic rhinitis (Urticaria, sneezing and watery nasal discharge).
Attacks are often relieved by injection or inhalation of bronchodilators or stroids. Most of the children
with bronchial asthma are often cured by school leaving age but the disease usually is chronic in
adults. Patients with bronchial asthma are usually non-smokers.
2. Chronic Bronchitis:-(Definition: Cough and expectoration of copious amounts of sputum occurring
for at least three months in a year for two consecutive years). The patient is often a middle-aged
smoker with history of breathlessness, cough and expectoration of small to moderate quantities of
mucoid sputum which may become muco-purulent at times of acute exacerbations. There may be
history of wheeze. Initially the symptoms are usually present during winter but with the progression
of the disease cyanosis and symptoms of cor pulmonale appear and the patient is breathless all the
time. The symptoms of chronic bronchitis are also partially relieved by bronchodilators and steroids.
3. Congestive Cardiac Failure: (Breathlessness is a feature of left ventricular failure which may or
may not be associated with right heart failure. However, right heart failure is often the result of
respiratory diseases which usually present as breathlessness). The patient complains of progressive
breathlessness on exertion, later on even at rest which may be associated with orthopnoea and
paroxymal nocturnal dyspnoea. There may be associated symptoms of cough with expectoration of
frothy white sputum (Due to pulmonary oedema) which may be blood stained. There may or may not
be associated symptoms of swelling of the feet (Oedema) or pain in the right hypochondrium (due to
hepatomegaly). Breathlessness is relieved by rest, diuretics and digoxin in most of the case. There
may be a past history of hypertension, Ischaemic heart disease or rheumatic fever.
4. Pneumothorax: (See under “Chest pain).
5. Pulmonary embolism:- (See under “Chest pain).

35
MOST COMMON CAUSES:
1. Angina pectoris
2. Myocardial infarction
3. Psychogenic chest pain
(De Costa’s Syndrome).
4. Non-Specific
-(Musculoskeletal) Chest pain
5. Pneumonia
6. Pneumothorax
7. Pericarditis
8. Pulmonary embolism.
Chest Pain
COMMON CAUSES:
1. Anxiety/emotion
2. Cardiac
 Myocardial ischaemia (angina)
 MI
 Myocarditis
 Pericarditis
 Mitral valve prolapse
3. Aortic
 Aortic dissection
 Aortic aneurysm
4. Oesophageal
 Oesophagitis
 Oesophageal spasm
 Mallory–Weiss Syndrome
5. Lungs/pleura
 Bronchospasm
 Pulmonary infarct
 Pneumonia
 Tracheitis
 Pneumothorax
 Pulmonary embolism
 Malignancy
 Tuberculosis
 Connective tissuedisorders (rare)
6. Musculoskeletal
 Osteoarthritis
 Rib fracture/injury
 Costochondritis (Tietze’ssyndrome)
 Intercostal muscleinjury
 Epidemic myalgia(Bornholm disease)
7. Neurological
 Prolapsed intervertebral disc
 Herpes zoster
 Thoracic outlet syndrome

36
1. Age: Young adults (Psychogenic chest pain, non-specific chest pain, pneumothorax), middle-aged
and old patients (Angina pectoris and myocardial infarction), all ages (Pneumonia and pulmonary
embolism).
2. Sex: Male (Angina pectoris and myocardial infarction), young females (Pulmonary embolism), either
sex (all other causes Chest pain).
3. Site: Retrosternal (Angina pectoris, myocardial infarction, reflux oesophagitis and sometimes
percarditis), Precordial region (De Costa’s Syndrome, Pericarditis), anywhere in the chest
(Musculoskeletal chest pain, pneumonia and pulmonary embolism).
4. Character: Crushing, Pressure-like or heaviness (Angina pectoris and myocardial infarction), dull
(Pericarditis and pleurisy), pricking (Psychogenic chest pain), bringing (Reflex oesophagitis).
5. Radiation:- Radiation to the neck, left shoulder and inner side of the left arm, rarely to the right
shoulder and arm (Angina Pectoris, myocardial infarction and pericarditis), No specific radiation (all
other causes of chest pain).
6. Duration of Attack: Few minutes, usually less than 30 minutes (Angina Pectoris), often more than
30 minutes, upto few hours (Myocardial infarction), a few second (Cardiac neurosis), Continuous for
hours to days (Pleurisy, pericarditis and musculoskeletal chest pain).
7. Aggravating Factors:- Cough and respiration (Pleurisy, pericarditis and musculoskeletal chest
pain), exertion (Angina Pectoris, Myocardial infarction), lying (Reflux oesophagitis) pressure
(Musculoskeletal chest pain, pleurisy and pericarditis).
8. Relieving factors: Sublingual nitroglycerine or isosorbide dinitrate (Angina pectoris, Sometime
reflux oesophagitis), pethidine, morphine or other strong analgesics (Myocardial infarction, also in
other causes of chest pain), antacids (Reflux oesophagitis).
a) Fever (Pneumonia, pericarditis, after myocardial infarction)
b) Cough: Dry (Pleurisy), frothy sputum (Left ventricular failure due to MI), Blood-stained
sputum (Pulmonary infarction due to embolism), rusty or yellowish sputum (pneumonia).
c) Sweating: Cold sweating (Myocardial infarction), sweating with fever (pneumonia).
d) Symptoms of anxiety (Cardiac neurosis).
e) Breathlessness: A nonspecific symptom associated with pneumonia, myocardial infarction,
pulmonary embolism, pneumothorax and even cardiac neurosis.
PAST HISTORY:
a) Previous good health (Spontaneous pneumothorax, pulmonary embolism.)
b) Chronic bronchitis and bronchial asthma (Pneumothorax).
c) Hypertension or diabetes mellitus or previous heart attack (Angina pectoris and Myocardial
Infarction).
d) Symptoms of anxiety (Cardiac neurosis).
FAMILY HISTORY:
Of heart attack (Angina pectoris and myocardial infarction), recent death of a near relative (Cardiac
neurosis).
PERSONAL HISTORY:
Smoking (Angina pectoris and myocardial infarction), use of contraceptive pills in young females
(Pulmonary infarction due to pulmonary embolism).

37
DRUG HISTORY:
1. Angina pectoris: Patient usually present with sudden severe pressure like, retrosternal chest pain
radiating to the neck, left shoulder and inner side of the arm, sometimes to the right shoulder and
arm, brought on by exertion and relived by rest. However, it may occur on lying (Angina
decubitus), or at rest (Unstable angina). Duration of pain is usually a few minutes and rarely more
than 30 minutes. It is usually not associated with sweating or breathlessness. Usually the patient is a
middle aged man who may be diabetic, hypertensive or smoker with a family history of heart
attacks.
2. Myocardial Infarction:- Usual description of pain is similar to that of angina pectoris except that it
is more severe, may come on even rest, lasts more than 30 minutes, does not respond to subligual
coronary vasodilators, needs strong analgesics e.g. morphine or pethidine for its relief and is often
associated with weakness, breathlessness, cold sweating and fear of impending death. Fever may
occur a few days after myocardial infarction.
3. Pleurisy: Pain due to pleurisy can be due to pneumonia or pulmonary infarction secondary to
pulmonary embolism. In a previously healthy person there is severe, dull or sharp pain in a specific
area of the chest. Pain is continuous localized, aggravated by taking a deep breath, often
accompanied by fever and cough which may be dry at first and later on productive of sputum (See
chapter on cough and sputum). Patient likes to lie on the affected side. The pain is not related to
exertion and analgesics transiently relieve the pain).
4. De Costa’s Syndrome (Cardiac neurosis):- The patient is often a young anxious person and may
have a history of recent death in the family from myocardial infarction or the patient may be related
to medical profession (Medical students, nurse or doctors). Patient usually complains of pricking,
precordial chest pain only for a few seconds but often repeated with palpitations, sweating,
insomnia, weakness, numbness of the body and difficulty in breathing. There is no relation to
exertion and pain is not often relieved by coronary vasodilators.
5. Pericarditis: Patient develops dull, continuous, retrosternal or precordial chest pain which may
radiated to the same sites as in angina or myocardial infarction, aggravated by breathing or
coughing and relieved by sitting or leaning forward. There is usually no effect of coronary
vasodialators.
6. Pneumothorax: Patient is often a previously healthy young person or a patient with a previous
history
of bronchial asthma, chronic bronchitis or pulmonary tuberculosis, who gets sudden, Sharp chest
pain on the affected side and then becomes breathless and cyanosed (depending upon the extent of
pneumothorax), which may persist until treated. Unless there is underlying or super-added infection,
there is no fever or sputum but persistent dry cough may be present.
7. Pulmonary embolism and infarction: Patient may be a young female taking contraceptive pills or
a bedridden obese person (Postoperative, postpartum case or after myocardial infarction), Who
develops symptoms of deep venous thrombosis. However, these symptoms may be absent. There is
sudden, severe chest pain followed by breathlessness and cyanosis. If the patient survives, initial
sharp pain is replaced by dull pleuritic chest pain due to pulmonary infarction which is aggravated
by cough and deep breathing. Cough may be productive of bloody sputum. In severe cases
symptoms of right heart failure may be present.
8. Reflux oesophagitis: Patient gives history of burning, retrosternal, constant chest pain which is
aggravated by lying flat and relieved by sitting, sleeping with head –end of the bed raised or by
antacids.

38
Palpitation
DEFINITION:
Palpitations are the awareness of cardiac contractions. These may occur in the presence of normal or
increased heart rate and regular or irregular rhythm.
COMMON CAUSES
1. Valvular heart disease
2. Arrhythmia
3. Anxiety
4. Anaemia
5. Pregnancy
6. Cardiac syncope
7. Paroxymal supraventricular tachycardia
8. AF or Flutter
9. Thyrotoxicosis
10. Drugs– -Salbutalmol
-Ca channel blocker
--blocker
-Theophylin
1. Duration and frequency: Long-standing, occurring daily or even several times a day (Sinus
tachycardia or normal rhythm), attacks with interval of freedom in days, weeks or months (PAT), on
and off (Extrasystole), continuous over a period (Atrial Fibrillation and atrial flutter).
2. Exact complaint: Missed beats (Extrasystole), heavy thumping beats (Sinus tachycardia or normal
rhythm) racing heart (Paroxysmal atrial tachycardia), fluttering beats (Atrial fibrillation or atrial
flutter).
3. Rate and rhythm:- If the patient has noted heart or pulse rate during the attack ask whether the rate
is normal with occasional irregularity (Extrasystole), regular with normal or increased rate (Sinus
rhythm or sinus tachycardia), regular, very fast, difficulty to count (PAT), normal or fast but very
irregular (Atrial fibrillation, sometimes atrial flutter with variable block).
4. Aggravating and relieving factors: Aggravated by anxiety, exercise, fever, smoking, strong tea or
coffee (Sinus tachycardia or paroxysmal atrial tachycardia), Relieved by sucking ice, vomiting or
stringing (PAT), not much affected by any factor (Atrial fibrillation).
a) Intolerance to heat, prominent eyes, thyroid enlargement, tremors (sinus tachycardia or atrial
fibrillation due to thyrotoxicosis).
b) Central chest pain on exertion (Ischaemic heart disease).
c) Breathlessness on exertion, orthopnoea, paroxysmal nocturnal dyspnoea and swelling feet
(Congestive cardiac failure).
d) Polyuria after attack of palpitations (PAT)
e) Insomnia, anorexia, generalized weakness, lethargy, easy fatiguibility (Normal sinus rhythm or
sinus tachycardia due to anxiety).
PAST HISTORY:
Ask about:
a) Hypertension, heart attack, rheumatic fever (Cardiac disease as the cause of palpitations).

39
b) Set back in life e.g. financial loss, death of a relative (Anxiety neurosis) as a causes of
palpitations.
DRUG HISTORY:
Ask about use of drugs which can causes palpitations i.e.
a) Drugs used in bronchial asthma (Aminophylline, Salbutamol, terbutaline).
b) Drug used in cardiac disease (Nifedipine, digoxin, atropine and isoprenaline).
1. Sinus Tachycardia or sinus rhythm: Palpitations usually occur with other features of anxiety or
could be due to drugs, smoking, coffee, tea, heavy meals or thyrotoxicosis. The patient usually
complains of heavy thumping beats with normal or increased rate and regular rhythm. Episodes of
palpitations may be long-standing, occurring daily or even several times a day. These do not indicate
any serious cardiac disease and often disappear on removal of the underlying causes.
2. Paroxysmal Atrial Tachycardia (PAT): Usual history is attacks of racing heart occurring with
intervals of freedom in days, weeks or even months. Rhythm is regular with a rate which is very fast
and difficult to count. Attacks may be precipitated by emotions, strong tea or coffee and can be a
feature of thyrotoxicosis. Patient may be knowign the tricks to relieve the attacks e.g. by inducing
vomiting, sucking ice, straining, and even massaging the carotid artery. An attack may be followed by
polyuria. In older patients there may be symptoms of angina or heart failure.
3. Extrasystole (Ectopics): Patient often complains of missed beats. The heart rate is normal with
occasional irregularity. From the history it is difficult to differentiate between atrial and ventricular
extrasystole. They are significant only if they are associated with heart disease or progress to causes
more serious arrhythmias.
4. Atrial fibrillation: Patient often complains of continuous, fluttering, fast and very irregular beats.
There are often symptoms of heart failure or of underlying disease e.g. Thyrotoxicosis.

40
Polyuria
DEFINITION:
Polyuria means passage of more than 3 liters of urine in 24 hours. It usually manifests as increased frequency
of micturation with large volume of urine passed every time.
COMMON CAUSES:
1. DM
2. Diuretic therapy
3. Chronic renal failure
4. Compulsive water drink
5. Hypercalcaemia
6. Diabetes inspidus
7. Following defervescence of fever
8. Following an attack of supra-ventricular tachycardia.
1. Onset: Sudden, patient even remembering the time and the date of onset of symptoms (Diabetes
inspidus), gradual (Diabetes mellitus, chronic renal failure, hyperclacaemia and compulsive water
drinking), under special circumstances (Diuretic therapy, following defervescence of fever or an
attack of supra-ventricular tachycardia.
2. Frequency of micturation: How many times the patient passes urine in 24 hours? This information
can help in diagnosis because increased frequency of micturation can also occur due to urinary tract
infection, when in contrast to polyuria very small quantities of urine are passed every time.
3. Timing of Urine Passed: During day time only (Compulsive water intake), during day and night (All
other Causes of polyuria).
4. Volume of Urine passed: Large volumes of urine passed every time (Polyuria), small volume of
urine passed every time (UTI or prostatism).
5. Type of Fluid Taken: Ice cold water (Diabetes inspidus), sweet drinks (Diabetes mellitus), any type
of fluid (All other causes of polyuria).
a) Polydipsia, Polyphagia, numbness, weakness, visual disturbances and ants collecting at the urine
(DM).
b) Headache and/or visual disturbances (Diabetes inspidus).
c) Anorexia, nausea, vomiting, diarrhoea, metallic taste in the mouth, hiccough, pallor and
breathlessness (Chronic renal failure).
d) Anorexia, nausea, vomiting, constipation and bone pains (Hypercalcaemia)
e) Symptoms of disorders for which diuretics are being given e.g. exertional dyspnoea, paroxysmal
nocturnal dyspnoea, orthopnea, swelling feet and pain right hypochondrium (CCF), distension
abdomen, discomfort left hypochondrium with or without jaundice (Cirrhosis liver), periorbital
swelling, distension abdomen and swelling feet (NS).
f) Symptoms suggestive of anxiety or depression (Compulsive water drinking or psychogenic
polydipsia).
g) History of attack of palpitations or high fever before polyuria.
PAST HISTORY
Ask about:
1. Previous head injury or operation on pituitary (Diabetes inspidus).
2. Treatment for diabetes mellitus.
3. Renal colic, pain in lumbar region or symptoms of protatism (Chronic renal failure.)

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FAMILY HISTORY:
Ask about other relatives suffering from:
1. Diabetes mellitus
2. Renal failure (Polycystic kidneys).
DRUG HISTORY:
Ask about the use of diuretics e.g. frusemide, Bumetinide, spironolactone etc. steroids and any
previous treatment for diabetes mellitus with dose of the drug used.
1. Diabetes mellitus:- This disease can occur in children, adults or in old age, Usual history is of polyuria,
polydipsia and sometimes polyphagia. Large voumes of urine are passed on which ants may collect. This
causes dehydration, weakness, weight loss and if untreated may lead to coma in younger patients. It is
often associated with delayed healing of wounds, pain in the limbs, generalized itching and loss of
sensations which may cause deep painless ulcers on the feet. These patients are often very fond of sweet
drinks and feet. These patients are often very fond of sweet drinks and food. There may be a history of
other relatives suffering from diabetes mellitus.
2. Diuretic therapy: Often the symptoms of the disease for which the diuretics are being given, are more
prominent than polyuria due to diuretics. Such a patient will have symptoms of congestive cardiac
failure or cirrhosis liver or NS for which a diuretic e.g. frusemide, spironolactone or some combination
diuretic is being used.
3. Chronic renal failure: Such a patient usually has a past history of symptoms suggestive of repeated
urinary tract infections, prostatism or renal colic. Polyuria is not as troublesome for the paient as are the
symptoms of anorexia, hiccough, nausea, vomiting, diarrhoea, metallic taste in the mouth, pallor and
breathlessness. In some cases e.g. polycystic kidney disease, there could be a family history of relatives
having or dying of similar disease.
4. Compulsive water drinking:- In such a patient there are often symptoms suggestive of anxiety or
depression. Polyuria is the result of excessive intake of water, which rarely wakes the patient from sleep.
5. Hypercalcaemia: Polyuria results from a decreased concentrating power of the kidneys dye to moderate
to sever hypercalcaemia. Symptoms include anorexia, nausea, vomiting, constipation, gritty red eyes and
if untreated can lead to confusion and coma.
6. Diabetes inspidus: There is a very sudden onset of polyuria and polydipsia with patient having a special
craving for inc-cold water. Headache and visual disturbances may be associated.

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