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The Art of
History Taking
His Excellency, the President of India, Dr APJ Abdul Kalam
has highly appraised the book and autographed on it.
The Art of
History Taking
Second Edition
Kashinath Padhiary MD FICP FCCP

Professor of Medicine
MKCG Medical College, Berhampur
Cuttack, Orissa, India
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The Art of History Taking

© 2009, Kashinath Padhiary
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and author will not be held
responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled
under Delhi jurisdiction only.
First Edition: 2004

Second Edition: 2009
ISBN 978-81-8448-622-3
Typeset at JPBMP typesetting unit
Printed at
To
My students ...
“Dear students
Nobody can teach you
Unless you try to learn
What a teacher can teach
He can only expose your ignorance
Don’t expect too much from the teacher
Because his knowledge is also limited
Rather, try to learn from the books
Under the guidance of your teacher
Never compromise the quality in learning
As the future (treating and teaching)
will be in your hand
We may not be excellent
But we all have a scope to excel”
PREFACE TO THE SECOND EDITION
The first edition of the book was a success across the world.
In this edition, I have tried to improve the language and
included a chapter on Fever on request of my students, which
will be very useful not only to the students but also the
practitioners.
A chapter on hematology has also been added. Though
hematological diseases form a small group of diseases, but
history taking is very important for diagnosis. I feel after
finishing the chapter one will certainly realize this. If
anything is more important than history taking in such
conditions, it is the detail blood analysis, particularly the
peripheral smear. Excluding the addition of these two
chapters, many other points in other chapters have also
been clarified.
The evaluation and documentation of the chief
complaints have been dealt with some details. The doubts
about the leading questions have been clarified. How to
avoid leading questions and how to interpret the answers
to the leading questions have been discussed. A new entity
in the name of community history has been added which in
the previous edition was included in the family history.
I hope readers will find this edition more informative
than the last one.
I shall be happy if I get suggestions from the readers
about improving the text in future editions of the book.
Kashinath Padhiary
PREFACE TO THE FIRST EDITION
Is there a need for such a book?

With the progress of scientific knowledge more and more
investigative procedures are available. These investigations
have helped to reach at a more complete diagnosis, but
simultaneously have increased the total cost of therapy. It is
my observation that younger generations of doctors are
becoming more and more dependent on these investigations.
Investigations always do not give clear picture; at times
confusing information is obtained where standardized
laboratories are very few. These young doctors do not realize
how much information can be obtained from a well taken
history and how it can limit the number of investigations;
thereby reducing the cost of therapy. Worldwide it has been
felt that there is an absolute need to reduce the cost of therapy.
I have tried to explain the amount of information we can get
from history in few important systems; but importance of
history is very much there in each and every case, medical,
surgical or gynecological or in other fields.
It is my observation over the years that undergraduate
students take a bizarre history. Postgraduate students also
take history without knowing the importance of every aspect
of the history. Often teachers just tell the students to collect
the history without teaching them how to take the history,
nor guide them while they are taking history. In view of PG
students, I have noticed that this is the practice more or less
everywhere. In fact, I have seen teachers giving undue
importance to physical examination and investigations.
x The Art of History Taking
None of the commonly available books of clinical methods
describe the intricacies of history taking. The pages covered
for history taking in these books is much less in comparison
to the pages covered for physical examination. When the
same thing is repeated at bedside, students fail to realize
the importance of history. At times confusing things happen.
For example, in history of present illness, no leading
questions should be asked, but in practice almost all
physicians ask leading questions. A beginner gets confused
by that. Similarly, chief complaints are supposed to be
recorded in patient’s own language, but often the language
the patient uses is not understood well, nor there is a
scientific counterpart available in the books. So the
information collected does not serve any purpose.
There are several other points which need clarifications.
I shall try to discuss these points so that the students will be
able to collect a fairly informative history. This book cannot
teach the total aspects of history taking. Once the students
realize the importance of history they can take better history
than I can describe or anybody can teach. I hope this book
will be of use to all the students of medicine.
Kashinath Padhiary
CONTENTS
1. General Considerations .......................................... 1

2. Personal Information ............................................ 19
3. Chief Complaints ................................................... 27
4. History of Present Illness ...................................... 47
5. History of Past Illness ........................................... 55
6. Family History ....................................................... 63
7. Community History .............................................. 67
8. Personal History .................................................... 71
9. Menstrual and Obstetric History ......................... 81
10. Treatment History ................................................. 87
11. History in Cases of Fever ...................................... 91
12. History in Cardiovascular Disorders ................ 107
13. History in Neurological Disorders .................... 123
14. History in Respiratory Disorders ...................... 151
15. History in Gastrointestinal Disorders .............. 165
16. History in Genitourinary Disorders .................. 199
17. History in Hematological Disorders ................. 211
18. History in Unconscious Patients ....................... 221
Index ...................................................................... 233
CHAPTER
1
General
Considerations
Be a man first, then the doctor.

See the man first, then the disease.
Don’t miss the forest for a tree.
2 The Art of History Taking
THE CLINICAL DIAGNOSIS
It is an age old saying that diagnosis should precede
treatment. To decide that somebody is suffering from a
disease or not, it needs evaluations of all aspects of
diagnostic principles. These principles are (i) history taking,
(ii) general physical examination (iii) systemic examination
(iv) investigations.
Each step has got significance. In some cases history
alone may be enough, in some cases systemic examination
may yield the maximum information and in the other cases
it may be required to ask for a series of investigations. As
one proceeds from history onwards, one should assess how
nearer he has come to the diagnosis at the end of every step.
In fact one can narrow down the differential diagnosis from
the chief complaints alone. For example, if the first
complaint is fever so many probabilities are there. But, if it
is associated with cough with expectoration (second
complaint) the probability is infection in the lower
respiratory tract. If the fever is of short duration it could be
pneumonia, if the fever is of long duration it could be
tuberculosis. So every case should be assessed after history
taking, after general physical examination and systemic
examination. By proceeding in this way one can narrow
down the differential diagnosis to a great extent. This will
help to plan the investigations properly and logically. This
will also improve one’s clinical skill. Proper planning of
investigations is very much required as some of the
investigations are costly and some are risky. The mentioned
order has also to be maintained. One should not first
examine the case without taking a thorough history.
General Considerations 3
Similarly, if you are dealing with a case which has already
been treated/evaluated by some other doctor you are likely
to be carried away by his opinion or by his investigations.
In such cases also one should go step by step in stead of
skipping any step. It is required to be remembered that the
value of clinical evaluation of cases has not declined over
the years even if so many investigative facilities have come
up. The merits of clinical evaluation are:
• Clinical diagnosis has been found to be the most cost
effective step in reaching at the diagnosis.
• It can be utilized anywhere: on the road, in the village,
in the train or in the hospital.
• It can be utilized several times on the same patient
without increasing the cost of treatment. Clinical
examination does not need maintenance cost, rather as
one utilizes more and more his efficiency increases.
• It does not need a power supply or a sophisticated
laboratory; so can be utilized during the time of natural
disaster.
• If one has understood the illness of the patient clearly he
can challenge certain reports which may prove to be
wrong. At least he can interpret the reports better. If he
has not understood the case clinically he is likely to be
misguided by an accidentally detected abnormality in
the investigation.
For all these reasons no doctor should leave any scope
to improve his clinical skill.
On the other hand, investigations are not always
productive. At times unreliable, at times ambiguous, at times
the patient may not be able to afford for costly tests. As there
are very few standardized laboratories in a country like
India, depending too much on the investigations might
prove harmful for the patient at times. In fact it has been
advised that “no doctor should request any special
investigation unless he knows what information relevant
to the problem, it is likely to provide, and has some idea of
its cost and of its possible danger to the patient”.
(HUTCHISON 18th Edition, Page: 4)
Importance of History Taking

With the advancement of knowledge diagnosis of human
disease has become easier and more precise due to
availability of several investigative facilities like X-ray,
ultrasound, echocardiography, CT scan, MRI scan and
others. However, the value of clinical diagnosis has not
decreased. All the investigations are only supplementary to
the clinical diagnosis. History contributes the major part to
the clinical diagnosis.
In the history taking we not only collect data about the
physical illness but also evaluate the feelings of a person.
How much impact the disease has put on the mind of the
person is known from history and this is required to give
total care to the patient. There is no machine to measure or
assess the feeling of a man. The patient might be suffering
from a fatal ailment, yet he might be happy; may be due to
ignorance. Similarly. patient might be too much worried
even if his illness is too trivial (out of fear). At times, it
becomes difficult for a person to express his feelings in words
and expresses in gestures.These gestures often give
important clues to diagnosis.
The physical examination and the investigations reveal
the changes present at the time of examination, does not tell
anything about the temporal profile of the illness. But, it is
the temporal profile of the illness which is most often
required to clinch the diagnosis. This is only brought out by
a thorough history taking. Even a probable diagnosis can
be known about an illness which occurred years back by
detail analysis of symptoms. This importance of history in
clinical diagnosis must have been realized by all physicians
in their life time. However, I want to quote one statement
from a leading book on clinical method, Hutchison’s clinical
method, 20th Edition.
Remember that the examination can only reveal abnormalities
present at the time of the examination. The history, on the other
hand can reveal aspects of the temporal development of the illness.
The history and examinations are thus complementary, but often
the history is more important.
History taking is important in cases of all systems. In a
neurological case one should be able to give three fourth of
the diagnosis at the end of the history taking. If this has not
been achieved history taking is told be inadequate.
(Bickerstaff:6th Edition,1996;page-8).The same author has
also stated. ‘No one can expect to go through his career and to be
right all the time, but most error arise from inadequate taking of
history and inadequate physical examination—particularly the
inadequate history.’
It is equally important in a respiratory case also. I have
felt that history gives more information in a respiratory case
than in a neurological case. Physical findings are often
confusing and unreliable. In relation to history in respiratory
case, Hutchison states—As with every aspect of diagnosis in
medicine the key to success is a clear and carefully recorded history
(20th Edition,1995; Page-141). Another leading author on
respiratory diseases, GK Crofton states ‘In many instances
careful history taking is more important than elicitation of elegant,
but possibly misleading physical signs’ (The respiratory system,
Macleod’s clinical examination, 9th Edition, 1995; page-
136). The clinical history and examination are fundamental
to assessment of respiratory health even in the epoch of
computer assisted tomography and broncho alveolar lavage.
In deed too great an emphasis on the technology of medicine
may lead to atrophy of clinical study and thus a loss of
judgment in the assessment of an individual’s health (The
clinical manifestations of respiratory diseases, Crofton and
Douglas’s Respiratory Diseases; A Seaton, D Seaton,
AG Leitech: 4th Edition,1989; Page-104).
In diseases of the gastrointestinal system too history is
equally important. Little information will be obtained by
examination of these patients. Pain is a common symptom
of intra-abdominal diseases. In patient with abdominal pain,
detail interrogation and clinical judgment is essential before
investigations are performed. If this is neglected unnecessary
tests may result in the discovery of asymptomatic
abnormalities such as hiatus hernia or gallstones, leading
to inappropriate management and even unnecessary
surgery. (The alimentary and genetourinary systems,
MJ Ford, DW Haner Hodges; Macleod’s clinical Examination
(9th Edition) 1995; Page-162).
From these quotes from different renowned authors and
from the experiences of my colleagues and from my own,
I can conclude that in every case history taking is of utmost
importance to reach at a diagnosis and for proper planning
of investigation and treatment. I shall discuss later in
respective system how history taking is important.
History Taking—an Art

History taking is basically a process of understanding the
feelings of an individual . These feelings are nothing but the
symptoms of different diseases. Feelings can not be
quantitated, can not be always expressed in scientific terms,
nor can be satisfactorily expressed in words. Scientific
understanding of a disease is nothing but understanding
the bodily changes in terms of changes in anatomy and
physiology. History taking not only tries to assess the bodily
changes but also helps to know its affect on mind. So, while
taking history, look how his body as well as mind has been
affected. This can be done by looking for the nonverbal
communications and the body language. In fact there may
not be any physical ailment at all, yet the patient becomes
symptomatic and the significance of these symptoms can
be known from the body language. How to study the body
language and the emotional aspect of an illness can not be
taught theoretically, hence this has to be learnt by observing
the patients under guidance; so this becomes an art. More
one observes/practices more efficient he becomes.
To take a good history, one has to go down to the level of
the thinking of the patient. It is required to understand
clearly the terms and words a lay man uses. One has to
know the exact nature of the work of the patient and how
the illness affects his day to day work. Understanding the
language of the patient is mandatory for correct assessment
of the history. This is particularly true for a country like
India, where people use several languages. Even in the same
language there are several colloquial words and terms which
are also to be clearly understood. Whenever required the
help of a good interpreter should be taken.
Because history taking is basically a mode of
conversation, so the doctor should encourage the patient to
speak freely without any reservation. An environment for
free talk should be created. You have to ensure him that you
also feel for his illness and you are there to help him.
Remember that while you are taking history the patient also
marks how attentively you are listening to him. If you show
dissatisfaction or displeasure, he does not feel like talking
and might give a confusing history. Similarly, if your
attention is diverted frequently to other things while
listening to the patient’s complaints, he feels that you are
neither interested nor attentive to his problem. For this type
of attitude, patients lose faith in the doctor even if he has
diagnosed and treated correctly. I shall give an example—
“A father took his young son to a renowned physician. The
consultant wrote the age of the child to be one and half
years in stead of one and half months and accordingly
prescribed the drugs. This was noticed by the father after
coming out of the consultation chamber. He returned back
and pointed it out to the doctor, but the doctor did not take
it seriously. The father lost faith in the doctor and did not
follow the prescription and went to another doctor. The
father had also marked that while the doctor was taking
history of his child he was often talking to others.” This
speaks that patients do notice how attentive you are to them.
So, during the time of consultation too many outsiders
should not be allowed to be present. This will make the
patient nervous; likely to divert the attention of the doctor
and the patient will not feel free to speak. This is more so if
the matter is related to sex and personal life.
Like any other art practice makes a man perfect, so also
in the art of history taking one has to practice daily to
improve. More one feels for the patient; more one gets
involved with the patient and one can extract more
information form the patient.
Often people do not know what to tell before a doctor
and do not understand which part of the history is to be
elaborated. This is either due to ignorance or due to
nervousness. What ever may be the reason it is the duty of
the doctor to collect a reliable history. To eradicate the initial
anxiety and nervousness from the patient’s mind try to greet
the patient by name whenever possible, try to discuss topics
unrelated to his ailment. One can comment on the dress,
can ask about his children in case of elderly people, about
his school and education in case of school going children.
At times these discussions can reveal key points too. If the
patient is giving unnecessary details of a minor point, in
stead of getting irritated on him, listen to him patiently and
simultaneously ask the details of those points which you
feel to be important. Often patients try to speak medical
terms without knowing their significance and meaning.
They should be dissuaded from that. At times patients tell
more about their treatment than about their illness. This
should be discouraged also. Also there are patients who
show several consultation papers without telling much
about their illness. Tell them to show the papers at the end
of the consultation, because these papers are likely to
misguide the examiner. However these papers have their
own importance which will be discussed later. I always
recommend students to evaluate the cases independently
and assess themselves after going through the papers of
experienced consultants. This will help to develop their own
thought process.
Never show dissatisfaction or displeasure in words or
in action while listening to the patient. For example, if a
patient passes urine or vomits before you, remain quite, ask
the attendant to clean the patient and the room, ask the
patient to relax on a bed for some time and then discuss or
examine him later. Similarly, if there is a foul smelling ulcer
or foul breath, do not sniff or spit before the patient. These
cases are often discarded by the family members and friends;
their only hope is the doctor. They feel that the doctor will
be able to do something to get rid of his problem and he will
be able to go back to his social life. In stead, if he feels that
the doctor also dislikes him, he may not feel like living and
might attempt suicide.
Grown up children will not like to undress before their
parents, but will not hesitate to do so before the doctor. This
speaks that the doctor is in an advantageous position; rather
he is in a better position than other relatives of the patients
including parents to know the facts about the patient. The
facts which are not told to the relatives may be revealed to
the doctor. However the doctor should not take its undue
advantage. He has to maintain the privacy of every patient
and the secrecy of facts revealed to him should be
maintained. It is a common experience that often doctors
become good friends of many patients, particularly elderly
people. These people often express unnecessary details of
their family matters. It is wiser to listen to them patiently.
Sequence of History Taking

Traditionally, the first thing to be collected is the bio-data.
These include age, sex, religion, address, and occupation.
Next the chief complaints, history of present illness, history
of past illness, family history, personal history, menstrual
and obstetrics history and treatment history are to be taken.
However, this scheme need not be strictly followed while
applying on an individual case. In fact some doctors
recommend taking past history and family history earlier
than the history of present illness. This helps to understand
the person and his illness more completely and clearly.
I personally agree with this recommendation. I am giving
two examples here how this is helpful.
Suppose, a case of rheumatic heart disease complains of
fever for fifteen days and also gives history of dental
extraction twenty days back. Here fever is the present illness
and tooth extraction comes under the past illness. If this
case is presented in a sequence like—a case of known
rheumatic heart disease (past history) had tooth extraction
twenty days back and now having fever for fifteen days
(present illness), it appears that this patient is suffering from
infective endocarditis.
Similarly, if a woman comes with unconsciousness and
she is pregnant also, it is better to tell from the beginning
that ‘a pregnant lady coming with loss of consciousness for
so many days duration’. Here one need not wait for obstetric
history to mention about her pregnancy. Presenting this
way makes the clinical situation clearer.
It is not important in what order history is collected
provided one does not miss any point and the examiner has
been able to understand every aspect of the history. In fact
in nervous patients it is wiser to discuss his personal life
earlier than about his illness, so that the patient gains
confidence and tells the history clearly. However, for
beginners it is better to stick to the sequence, so that they
will not miss any point. Similarly, in critically ill patients
few points from history should be collected and no delay
should be made to institute the first aid to save the life of the
patient . Once the condition of the patient is stabilized details
of the history can be collected. One should not waste time in
getting unnecessary details of the history when the patient
is in a gasping state. Here are the situations where treatment
precedes the diagnosis, though in most other situations
diagnosis should precede treatment. I have seen students
taking history from the relatives while the patient is already
dead.
The Leading Question

Ideally patients should be asked to narrate their story in
their own words. We should avoid leading questions.
A Leading question is that which suggests its answer,
usually as yes or no. But many patients do not give a cohesive
history. So, most of the doctors ask some direct questions to
extract more information from the patient or to clarify some
points. Often these questions are asked as leading questions.
While interpreting the answers to these leading questions
the physician has to be very careful. These answers should
be cross verified, about their reliability. Often the patient
replies in yes, to emphasize his complaints. He feels that
possibly such things are required for clear understanding
of his illness. He replies in no if he wants to hide some
points. People commonly give negative reply in relation to
extramarital sexual affairs and alcohol consumption. These
actions are not acceptable well in Indian society. People
often deny any personal problems in the family, because
discussing personal familial problems outside is also not
accepted well in our society. In fact some authors say that
the best physician is he who can interpret the leading
questions. I shall discuss a few points how to avoid leading
questions and how to interpret leading questions.
a. How to avoid: Let us discuss a few situations how to
avoid leading questions.
• Suppose you want to know about the appetite of a
person. If you ask is your appetite good? It becomes a
leading question; because the answer will be in the
form of yes or no. To avoid such a question ask what
he takes in breakfast, lunch and dinner. He should be
able to tell. You can compare it with what he used to
take previously. If his appetite is really decreased he
would tell that he is not taking anything, he is only
able take a little of the food served to him and leaving
the meal half way.
• If you want to know about one’s sleep in stead of
asking how your sleep is, ask when he goes to sleep
and when he gets up? From this one can assess
whether he is getting enough sleep or not? If he is not
getting enough sleep he would tell that he is spending
the whole night without actual sleep or he gets up
after a few hours of going to bed and there after he
spends whole night without sleep.
• Suppose you want to know whether he is having
dyspnea or not. In stead of asking such direct question
you can ask what physical work he does daily and
how this is affected. If he says that he is not able to do
it as he used to earlier because he feels breathless,
possibly his complaint of dyspnoea is true. In this
way very often it will be possible to avoid leading
questions.
b. How to interpret: If it is not possible to avoid leading
question one should know how to interpret leading
question. Let us discuss a few examples.
• Suppose you want to know the effects of previous
drugs prescribed by some other doctor, you should
ask what were the complaints, what were their
severity before taking those drugs and what is the
state of these complaints now. This is a frequent
observation that patients abuse their previous doctor.
It is not uncommon to listen from them that all the
complaints have worsened after taking the drugs
prescribed by his previous doctor. Even if they have
really improved by the treatment of their previous
doctor they blame him just to win the sympathy of the
present doctor (indirect flattering). The other reason
why they speak like that is, they expected complete
and quick recovery that might not have happened.
• If you want to know the regularity of consumption of
the drugs (say antihypertensive or antidiabetic drugs)
very likely you will ask—are you taking the drugs
regularly? He will most probably tell yes. But one
should not accept without further verifying. The way
to verify is to ask, “Did you take the drugs yesterday?
Did you take on the day before yesterday? Did you
take it on last Sunday?” If the patient has not taken
the drugs regularly he will admit on which days or
for how long he has not taken the drugs? He will tell
the truth because he will think that the doctor is
possibly able to know that he is not taking the
medicines regularly. In fact by asking in this manner
it will be possible to know that he is completely
irregular in consumption of the drugs.
• The points discussed under verification of genuine
nature of the complaints (discussed later) can also be
utilized for correct interpretation of the leading
questions.
From Whom History to be Collected?

Under ordinary circumstances patient himself should tell
the history. However, it is commonly observed that relatives
of the patient try to interfere in history collection. This should
be discouraged. Even the most uneducated patient can tell
about his illness with a little guidance from the doctor.
• In case of a child, history should be collected from the
parents, preferably from the mother. If details of the
illnesses of childhood of any patient are required, they
can be collected from the parents or from any other senior
family member who knows about his childhood.
• In unconscious patients history should be collected from
the persons who were present during the onset of the
illness (often this gives clue points to diagnosis). He
may be a family member, room-mate, classmate,
colleague or a teacher.
• In patients with transient loss of consciousness like
epilepsy or transient ischemic attacks, history should
be collected from an eye witness. If the incident happened
on the road history should be collected from him who
first attended the victim.
• History of mentally retarded or deaf and dumb person
should be collected from the people who ordinarily take
their care. Because, they can notice the slightest changes
in their activity/behavior or mark the earliest symptoms
of their illness.
Observing for Nonverbal Communications

While the patient is telling the history, observe the patient
closely. Even one should start observing much before the
patient speaks his history. The words he uses, the emotional
attachment to the words, movement of hands and other body
parts, etc. should be marked. These are very important
findings; at times more important than what the patient
says (action speaks louder than the voice). Let us discuss
few:
• While describing the anginal pain, the patient may start
crying. This signifies the severity of pain. If he is moving
his hands over the sternum; it suggests that the pain is
retrosternal in site.
• While describing the abdominal pain if the patient is
moving his hand over a wide area on the abdominal
wall, it is likely that the pain is diffuse; not localized.
• If he points the site of pain with a finger, it is a localized
pain as seen in pleurisy.
• If a patient is groaning with abdominal pain likely that
it is a colicky pain.
• If a patient comes with a cloth tied over the head or on
the abdomen very likely he is having headache or
colicky abdominal pain respectively.
• If a patient is talking in a loud voice he is either nervous
or deaf. If a patient is talking in a low voice, often looking
at this side or the other, probably wants to speak
something about sexual problem.
• If a patient is wearing a warm dress (shawl or sweater)
in summer season likely that he is having a sensation of
chill (possibly due to fever).
• If a patient is not able to complete a sentence in one
breath his vital capacity is low.
• If the patient is giving extensive details of his illness
and treatment, he is likely to be a hypochondriac.
• At times patients produce a list of complaints written
down on a paper (often as many as ten to fifteen of them).
Possibly none is genuine, suggesting that they are
hypochondriac too.
• If a patient comes with a stick, it is likely that he is not
sure of his stance or gait (either due to weakness or due
to ataxia).
Chronic bodily illnesses often put their impact on the
mind. These patients move from doctor to doctor and if still
don’t get relief; they get depressed. They feel that they are
suffering from an incurable disease. The depressed mood
can be marked from their facial expression and from their
mode of talk. Likewise there are many more things which
can be observed while taking history.
I tell them as obvious, means even a common man will
be able to see them. One should not miss these obvious
findings while collecting the history. To an observant eye
many things are obvious. So, like practicing history taking
one should try to improve his power of observation.
CHAPTER
2
Personal
Information
Uncommon manifestations of
common diseases are more common
than common manifestations of
uncommon diseases.
Before collecting details of the ailments one should collect
certain personal information like age, sex, locality, occu-
pations, etc. At times these points hold the key to reach at a
diagnosis.
AGE
Of all the variables age is the single most point contributing
to causation of diseases. Aging is inevitable, so also the age
related problems. Problems in elderly individuals are
dementia, osteoarthritis, coronary artery disease (CAD),
blindness due to cataract and so on. Chances of developing
various types of malignancies increase with advancement
of age, but some cancers like chronic lymphatic leukemia,
multiple myeloma are mostly seen in elderly individuals.
Some problems are common to children. Most of the
congenital conditions are commonly encountered in
childhood, at times in very early childhood. However, there
are few congenital conditions which can manifest for the
first time in adult life like coarctation of aorta, bicuspid aortic
valve, rupture of Berry aneurism leading to sub-arachnoid
hemorrhage and so on. In-born errors of metabolism may
present from early childhood. Excluding the congenital
disorders; other conditions which are common to childhood,
are poliomyelitis, diphtheria, whooping cough, measles, etc.
Nutritional deficiency conditions are also common in
children as their requirement per kg body weight is more.
Kwashiorkor, marasmus, and vitamin A deficiency states
are common in children. Though most of the malignancies
are uncommon in children, but some malignancies are more
Personal Information 21
frequently encountered in them. These are Wilm’s tumor of
kidney, acute lymphatic leukemia, retinoblastoma,
craniopharyngioma, medulloblastoma. Other common
problems in children are foreign body in nose, ear or in the
respiratory tract. Acute rheumatic fever and Friedreich’s
ataxia are seen between 5 to 15 years age group.
Many of the diseases found in old age might be primarily
due to aging. Similar diseases if encountered in younger
age there could be some specific precipitating factors/risk
factors. For example, a person of seventy years of age may
suffer from CAD without having any risk factors, but if the
same illness is encountered in a 40-year-old individual there
could be some risk factors like smoking, hypertension etc.
Similarly, if an elderly person presents with cerebrovascular
disease it may be due to atherothrombosis; but if it is seen in
a young person it may be due to cerebral embolism due to
coexistence of rheumatic heart disease like mitral stenosis.
With same complaint diagnosis will be different
depending on the age. A child presenting with bleeding per
anum might be suffering from rectal polyp and the same
complaint in an elderly person might be due to rectal
carcinoma.
These are just a few examples where age helps in making
a diagnosis. But there are innumerable conditions where
age plays a significant role in the causation of disease. Age
is not only required for making a diagnosis, but also required
for prescribing certain drugs. Digitalis is better tolerated by
children than adults. Tetracycline can cause permanent
staining of the teeth in children, quinolones can retard bone
growth in children, opium alkaloids can cause marked
constipation in elderly individuals, glucocorticosteroids for
a long period in children can cause retardation of bone
growth and the same in elderly individuals can cause
pathological fractures.
Disease remaining same outcome and response to
treatment vary with age. For example, idiopathic
thrombocytopenic purpura carries better prognosis in
children than in adults. Nephrotic syndrome in children
responds to steroids better than nephrotic syndrome in
adults.
SEX
Sex is also an important factor towards the causation of
disease. As such diseases of the reproductive system will be
found in the respective sex. Excluding those most of the
diseases are more common in males. However, some diseases
are more frequently encountered in females. Most of the
endocrine disorders like Sheehan’s syndrome, Addition’s
disease, Cushing’s syndrome, thyrotoxicosis, hypo-
thyroidism are more common in women. Rheumatoid
arthritis, SLE and other collagen diseases are also more
common in females. Bronchial adenomas, primary
pulmonary hypertension, Sydenham’s chorea are also more
common in females.
Diseases which are transmitted as X-linked recessive
mode are seen in males. Some such examples are
hemophilias, G-6-PD deficiency, red-green color blindness,
gout due to deficiency of HGPRT enzyme, Duchene type
muscular dystrophy. In a country like India smoking and
alcoholism are mostly seen in males; hence smoking and
alcohol-related diseases are more common in males.
GEOGRAPHICAL LOCATION
There are several diseases which are seen more frequently
in certain geographical areas. This may be due to the
environmental factors, genetic constitution of the people or
due to certain practices peculiar to the place. Let us see a
few examples.
• Chaga’s disease is seen in South American countries
like Brazil, Argentina, Uruguay, Paraguay and Chile.
• Sleeping sickness is seen in Central and West African
countries.
• Thalassemia is common in Mediterranean countries,
though there are pockets in other countries too.
• Multiple sclerosis and sub-acute combined degeneration
of the cord and pernicious anemia are common in
temperate climate.
• Various types of encephalitis are also seen in specified
geographical areas.
• Carcinoma stomach is more common amongst Japanese
though coronary artery disease is less amongst them.
• Khangri cancer is common in Kashmir due to the habit
of keeping a burning pot at abdomen.
• In India goiter is common in sub-Himalayan areas
(Jammu Kashmir, Punjab, Himachal Pradesh, Delhi,
Uttar Pradesh, Bihar and West Bengal). This region is
considered as the largest goiter belt in the world. This is
due to less content of iodine in the water.
• Fluorosis is seen in certain places of Andhra Pradesh
(Prakasam, Nalgonda, Nellore districts), Punjab,
Haryana, Karnataka and Tamilnadu. Kala-azar is seen
in states like Bihar and parts of West Bengal.
Dracunculosis is seen in Rajasthan where people use
step wells. Most of the helminthic infestations and other
water borne diseases are common in those countries
(developing countries) where disposal of feces is not
proper and safe drinking water is not guaranteed.
• Bancroftian filariasis is more common in the coastal
regions of Orissa, Andhra Pradesh, Tamilnadu, Kerala
and Gujarat.
• In those areas where vaccination is not widely done
diseases like poliomyelitis and tetanus do occur.
• Certain diseases are not seen at certain places like Rabies
is not seen in Australia, New Zealand and Japan; Yellow
fever is not seen in India.
OCCUPATION
In addition to the above personal factors, occupation of the
person at times contributes to the causation of ailments.
While collecting occupation one should ask in detail about
the exact nature of the work and how much work is affected
by his illness. A man working in coal mine is likely to suffer
from anthracosis. But he who only does the work in the
office (say a clerk) and not exposed to the coal field will
certainly not suffer from the illness.
• Various types of Pneumoconiosis are by far the most
common type of occupational disorders. Silicosis (silicon
dusts) is seen in workers in sand blasting, metal
grinding, ceramic industry, building and construction
works, etc. Anthracosis (Coal workers), asbestosis
(Asbestos workers), Byssinosis (Textile workers) are
some of the examples.
• Persons taking care of animals (veterinarians) are more
likely to suffer from brucellosis.
• People carrying animal skins on their back are more
likely to suffer from anthrax.
• Sewerage workers are more likely to suffer from
leptospirosis.
• Lead toxicity is seen in people working in lead industries.
• People exposed to chemicals like benzene may suffer
from hypoplastic anemia.
• Prolonged exposure to ionizing radiation and other types
of radiations like X-rays can cause hypoplastic anemia/
leukemia.
• Non-vaccinated farmers and gardeners are more likely
to suffer from tetanus.
• Bird handlers suffer more often from psittacosis and
ornithosis.
There are many more conditions related to occupation.
In relation to occupation one should enquire about the
present as well as past occupation and their duration. If
there is a change in occupation the reason for it must be
searched for. It might be his illness that has forced him to
change the job.
CHAPTER
3
Chief
Complaints
With the observations of thousands

of our colleagues the knowledge has
reached this state.
Don’t allow the power of observation
to decline.
There are several points which need clarification in relation
to the chief complaints.
THE CHRONOLOGICAL ORDER

Chief complaints are the complaints which bring the patient
for medical help. Often this helps to reach of a diagnosis.
However always it may not be possible to understand the
complaints of the patient clearly. Here one can suggest few
words or phrases to the patient so that it becomes
scientifically meaningful. All complains should be recorded
chronologically. This is required because; all the symptoms
may be the manifestations of one illness at different stages
or one may be related to the other as a cause and effect.
Ordinarily, the patient complains of that which he thinks to
be important. But for the purpose of diagnosis this may not
be true.
Let us Discuss a Few Examples

Example 1: A patient may come for hemoptysis (say for
2 days), but he fails to tell that he was having cough for two
months. Here the patient deliberately does not do this. He
does not understand that both might be related to each other.
He complains of hemoptysis because he feels it to be an
alarming symptom. If hemoptysis would not have occurred,
he would not have come for medical help. For him
hemoptysis is important. But for the doctor both cough and
hemoptysis are important. So truly, the chief complaints
will be
Cough 2 months
Hemoptysis 2 days
Chief Complaints 29
Here the cough has not been complained by the patient,
it has been extracted from him. Still than, it should be
mentioned in the chief complaints as this will give better
information about the illness. This may be a case of
pulmonary tuberculosis or a case of bronchogenic
carcinoma.
Example 2: A patient comes with the chief complaints of loss

of consciousness (say for 2 days), on enquiry it was found
that he was also having fever (say for 7 days). Here again
even if the chief complaint for the patient is unconsciousness,
but for the doctor the chief complaints will be
Fever 7 days
Loss of consciousness 2 days
This will help in the diagnosis. It might be a case of
cerebral malaria, meningitis or encephalitis. The second
complaint fever which has only been revealed by the doctor
minimizes the possibility of being other cause of
unconsciousness.
Example 3: A case came with the complaint of hematemesis

(say for 1 day), but on further interrogation it was revealed
that he was having fever with joint pain (say for 5 days). It
was also revealed that hematemesis developed only after
receiving some drugs for fever and joint pain. Here his illness
started with fever and joint pain. To get relief from pain he
took some analgesics which caused erosive gastritis, leading
to hematemesis. So truly hematemesis is not a part of the
original illness. It is a complication of the treatment. While
treating such a case both aspects have to be considered.
So the true chief complaints in this case will be
Fever 5 days
Joint pain 5 days
Hematemesis 1 day
RECORDING THE CHIEF COMPLAINTS

Chief complaints are to be mentioned in patient’s own
language. This often creates confusion amongst the students.
It is not always possible to understand the complaints of
the patient clearly as he uses his own language. One should
first try to understand his complaints clearly and then the
complaints should be written in a scientifically meaningful
term/word. At times patient shows a particular body part
and says, “This has happened”. Here the doctor should see
what has happened and convert his visual findings into
scientifically meaningful word/term. For example, a female
patient came and showed her finger tips and told, “This
has happened.” On inspection it was found that she has
developed dry gangrene of the finger tips. Though in the
words of the patient the chief complaint was “This has
happened” but the true chief complaint to be mentioned is
blackening/darkening of the finger tips. If you write dry
gangrene of the finger tips it would be too much scientific
term, not the true complaint of the patient.
GENUINE NATURE OF THE COMPLAINTS

Patient is not a technical man. So he does not understand
the implication of what he says. At times, it becomes difficult
to make out the complaints of the patient. These misunder-
standings can lead to erroneous diagnosis. So always try to
Chief Complaints 31
verify whether the complaint is genuine or not. This is very
important. It might appear surprising that people can come
to a doctor without genuine medical problems. But, it is
possible. People come with various purposes to the doctors
with vague complaints. It may be for blackmailing others,
getting better compensation, for availing leave from duty, to
get insurance benefit and at times the patient expresses his
mental problems as physical complaints and so on. Often
female patients do not frankly complain of their menstrual
or genital problems and complain of vague physical
symptoms. So before proceeding further in history taking
one should be clear that the complaints are real. To ascertain
the genuine nature of the complaint the doctor has to clearly
know the exact nature of the daily work of the patient and
how the complaints affect his work. If the patient is not able
to do his work as efficiently as he used to do them earlier,
possibly his complaints are genuine. More important is how
it affects his daily activities like feeding, drinking, defecating,
urinating, etc. Particularly, if these activities are repeatedly
affected or affected for a long time the complaints are real. If
the complaint is such that the overall condition of the patient
has deteriorated, then the complaint is likely to be genuine.
Once it is established that the complaint is genuine patient
has genuine illness; whether it is revealed by examination
and investigations or not. If not revealed easily he needs
follow-up or more sophisticated tests. Let us discuss with a
few examples.
• Suppose the patient complains of vomiting for several
months and not able to retain anything he takes, he
should have evidence of weight loss/dehydration. If not
found his complaints might not be genuine. In such
situations he may be asked to collect the vomitus and
show. He might be bringing out some amount of saliva
each time.
• That the complaint of cough is genuine can be known—
whether it disturbs sleep or not, particularly of the family
members. In fact, patients with cough are often brought
for medical consultation by their family members. If the
family members do not say about this it could be an
unreal complaint. I have seen patients who present with
history of chronic cough are truly cases of tics. These
patients do not cough once they are asleep.
• If the patient is having polyuria his sleep should be
disturbed. In fact patients of polyuria present at first
with nocturia (nocturnal polyuria). Though there will
be day time polyuria as well, but patients do not
complain as nobody counts how many times he passes
urine in day time. If at all there will be doubt he can be
instructed to measure the 24 hours urine output for a
week or two.
The non-verbal communications also help to know that
the complaint is genuine. For instance:
• If an adult person is using oil-cloth on his bed, he must
be having fecal or urinary incontinence.
• If the patient is carrying a spittoon with him all the time,
he must be having profuse expectoration.
• If arrangements have been made for a patient to use toilet
at bed side, he is possibly he has muscular (weakness)
or skeletal (severe joint pain/fracture) problems. At times
such arrangements are made for elderly patients or
Chief Complaints 33
children having very frequent defecation as in bacillary
dysentery.
• If a young man is using a stick to walk he might be
having weakness or ataxia involving the lower limb.
• If a patient has got weakness of one upper limb he will
be doing his work either by his other hand or he will be
dependent on others for his work.
In this way, it is possible to know the genuine nature of
the complaint in many situations. In fact in most of the
situations it is obvious to know the genuine nature of the
complaint. In relation to this issue one should know that—
the complaint of fever (elevated body temperature recorded
by thermometer) and significant weight loss are invariably
genuine. At the same time it has to be remembered that if
the nature of complaint cannot be known with certainty,
the patient must be kept under observation. It should not be
passed off casually.
Students often fail to understand this point and get
confused. Some complaints are often wrongly interpreted
like transient loss of consciousness and convulsions. Let us
try to explain how to ascertain the genuine nature of some
of the complaints which are commonly confused.
Convulsions
People often misinterpret restlessness and abnormal limb/
body movements as convulsion. While collecting history in
such cases ask exactly what happened from an eye-witness.
The following points will help:
• You can show yourself the convulsive movements before
the attendants and compare it with what they have seen.
Or you can ask them to show how the movements were?
• Ask whether it occurred while under attention or not.
If it happens while the patient is not under observation
it is probably genuine. If the incident occurred in a public
place (like road or market), it is more likely to be genuine.
If it occurred in domestic environment, either is possible.
• Whether the patient had a fall or not? If there was a fall;
whether it was associated with injuries or not? If a patient
falls knowingly he will try not to hurt himself, at least he
will protect the head. He will try to fall by putting his
hands on the ground or putting his hip on the ground.
Fall from sitting or sleeping posture is possible with
true as well as hysterical convulsion; where as fall from
standing posture is more likely to be organic. If at all a
person tries to fall from standing posture he will sit first
and then he will fall.
• If possible try to see the fall or the abnormal movements
which the relatives tell to be convulsion. This will make
things clear.
• Ask for other associated features like tongue bite,
involuntary passage of urine, twisting of the head,
rolling of the eye ball and so on. All will go in favor of a
true convulsion. In true convulsion, there is a
definite pattern of movement of the limbs or body; where
as in hysterical convulsion the movements are often
bizarre.
Chief Complaints 35
Loss of Consciousness
Loss of consciousness is an indication of some form of a
major illness. This must be differentiated from those who
feign to be unconscious. The points to differentiate are:
• Many of the points discussed under the previous
heading will also help in this situation. Involuntary
passage of urine, stool on the bed; fall leading to injury
particularly to the head suggest there is genuine loss of
consciousness.
• Often people say that the patient is losing consciousness
off and on (several times within a short period). This
does not happen in true loss of consciousness. This can
only be possible in hysterical condition.
• Sometimes, people say that the patient regains
consciousness on closure of the nose. This also suggests
hysterical state, not true loss of consciousness. However,
this method should never be practiced, can be dangerous
if the patient is really unconscious.
Breathlessness
Often we encounter patients coming with complaints of
breathlessness, which is not true breathlessness. Such
complaints are more common in young women and children
of school going age. However, true breathlessness is a grave
complaint. So enough care has to be taken to differentiate
them. Often these cases present with just hyperventilation.
True nature can be ascertained by enquiring how this affects
his daily living.
• If a man doing physical labour to earn his livelihood
complains of breathlessness it is mostly genuine.
Because for breathlessness he would not be able to go to
work and for that his earning will be seriously affected
and his family will suffer. In fact these people continue
to work in the early stages of the disease in spite of being
breathless.
• At times such people change the type work. I remember
a patient who was doing physical labor, changed to
become a salesman in small shop. He earned less by
changing the work. He did this because he could not do
physical labor due to breathlessness.
• In a child this can be ascertained how it affects his
playing. If he is going to school, ask what game he plays
and how efficiently. Is he forced to take rest in the middle
or at half time? If he is not a school going child ask
whether he is able to play satisfactorily with his siblings
or children in the neighbourhood. At times the mother
might say that the younger child is able to do more work
than the elder one; signifying that the complaint of
breathlessness of the elder child is genuine.
Weight Loss
Often people exaggerate the complaint of weight loss. It is
not uncommon to hear the complaint of fifty percent weight
loss; which might mean that if a person’s weight was 50 kg
earlier now it has become 25 kg. This is not always acceptable
or believable. True weight loss can be known in the following
manner:
Chief Complaints 37
• Ask for his previous weight and when it was recorded
and why it was recorded? From the present weight you
can calculate the weight loss over that period.
• If the patient is not able to tell the previous weight, weight
loss can only be assumed. This can also be assessed
fairly well from the clothing. If the trouser which has
been stitched recently has become too loose, there is
significant weight loss. At times the people who were
not using belt earlier have started using belt now or those
who were using belt have made more holes in it. Both
these facts are reliable evidence of weight loss. Similarly,
in females looseness of the blouse can be utilized to assess
the reliability of weight loss. Both these observations are
based on science. One is the measure of waist
circumference and the other is the mid-arm
circumference. Once significant weight loss is
established, very likely there is a genuine illness.
Appetite
Frequently patients complain of loss of appetite. How
genuine it is, can be known from the person who ordinarily
serves him food; may be mother or wife or the cook.
• What is his usual food habit (quantity and quality) and
whether there has been any change in this habit or not,
can be ascertained from them.
• A person complaining of anorexia for several days but
without its affect on the general health of the individual
may not be genuine. If the anorexia is of short duration
this may not be true, rather there may be associated
symptoms of nausea and vomiting as in acute viral
hepatitis.
• Similarly exaggerated appetite is seen in cases of type-I
diabetes mellitus. It is not unusual to listen from the
parents that they are tired of giving food to their child
(ordinarily parents do not complain about the amount
of food their children take). It is also heard that such a
patient often steals food. I saw such a boy who used to
sell breads in his own shop. His father complained that
he is eating almost half of the breads brought for sale.
Vomiting
If a patient complains of vomiting off and on for a prolonged
period, it is supposed to affect his nutrition and hydration
status. If no such effect is noticed than the complaint is
unacceptable. In such cases try to find out some other
complaint which is misunderstood as vomiting. It could be
fictitious vomiting also. Each time he might be bringing out
only a little amount of saliva or there might be retching
only. This can be further ensured by asking the patient to
collect all the vomitus and produce before the doctor.
Fever and Chill

In relation to fever, confusion arises on the degree of fever
and the type of fever (like continued, intermittent or others).
Often people say that the patient had very high fever, so
much so that it was not possible to put the hands on the
patient’s body. This may or may not be true, because often
people exaggerate to emphasize the complaint. If the patient
Chief Complaints 39
or any other medical personnel has recorded the temperature
and it shows that it was really high then it is alright; if such
a record is not available then no conclusion can be made.
Similarly, often people say that the type of fever is
intermittent. This may be either truly intermittent or falsely
intermittent. If the fever subsides under the influence of
antipyretics it is likely to be falsely intermittent. If fever
subsides automatically, it is truly intermittent. Each has got
its own significance. So enquire whether fever subsides
automatically or due to intake of some drugs.
In a case of pneumonia a single shaking chill at the
beginning is expected. Under such settings if there are
repeated chills, it will suggest the development of empyema
or lung abscess. But before coming to this conclusion one
should see that it is not due to the administration of
antipyretics. Because, each time the patient takes antipyretic,
fever comes down and as the body regains temperature there
occurs chill.
At times people (particularly young females) complain
of fever for several days without any other symptoms or any
adverse effect on the body, so that they look completely
healthy. Before subjecting these cases for detail investi-
gations ask the family members (not the patient) to maintain
a temperature chart at least four to six times a day for a
period of at least one week. If the record shows fever then
proceed for investigation. If fever is not recorded very likely
it is psychogenic in nature. I have seen a few such cases
where by simply asking to record the temperature chart has
cured the illness. Details about fever are described in the
chapter of fever. Remember that if there is recorded fever in
any case, there is organic illness.
Hemoptysis and Hematemesis
The usual confusion between hematemesis and hemoptysis
is always there. Because, whatever blood comes from mouth
is considered as blood vomiting by common people (they
do not know the anatomy). So it becomes imperative on the
part of the doctor to enquire in detail and decide which is
true. The associated symptoms like cough, nausea, the act
of vomiting, melena, encephalopathy, colour of blood,
presence or absence of clot or food material, froth will help
to decide. All these points are to be taken into consideration
to reach at a conclusion, because one or the other point may
not be fulfilled in a particular case. If by chance the patient
vomits or spits blood in front of the doctor then it becomes
easier to come to a conclusion.
In relation to the amount of blood loss (irrespective of
hematemesis or hemoptysis) people often exaggerate. It is
not uncommon to hear a complaint that the patient vomited
a bucket of blood. But this is not possible; a bucket of blood
is not there in human body. So in stead of out rightly
accepting this, one should verify objectively the amount of
blood loss. One should not forget to examine the oral cavity
in all such cases. I remember a case who presented with the
complaint of hematemesis. But the amount of blood loss he
indicated by showing his hand and the absence of melena,
raised doubt about it. She was investigated for hemoptysis
yielding no result (X-ray). On re-enquiry he told that he had
a convulsion following which he brought out that amount
of blood. On examination of the oral cavity, a tongue bite
was detected.
Chief Complaints 41
Poisoning
In relation to poisoning also, the relatives often understate
the amount of poison ingested. One should never be carried
away by these statements. Always assess the amount of
poison consumed from the physical signs. However one
must remember some basic things while dealing with a case
of poisoning.
• The time gap between the intake and examination of the
patient
• Whether he has vomited immediately after intake of the
poison or not
• The time lag between intake of the poison and gastric
lavage (if done)
• Has he received any treatment prior to your examination
• Possibility of cocktail poisoning.
THE STARTING COMPLAINT

Always emphasis should be given to collect the correct
starting complaint. What was the complaint when the
patient first felt that he was not well? With the progress of
the illness more and more symptoms (even more ominous
symptoms) might have been added to the starting complaint.
But the starting complaint signifies the nature of disease
and organ involved. Let us discuss few examples.
An unconscious patient had fever and neck rigidity. It
could be a case of meningitis or a case of subarachnoid
hemorrhage. Here what will decide is the starting
complaint. If the starting complaint is severe headache (no
fever at that time) it is likely to be a case of subarachnoid
hemorrhage. Whereas, if the starting complaint is fever; it is
likely to be a case of meningitis.
A woman in advanced pregnancy comes with
convulsion and loss of consciousness and on examination
she was febrile also. It could be eclampsia or it could be a
case of infective condition of the central nervous system
(like encephalitis). If the relatives categorically deny that
there was no fever at the beginning of the illness and it all
started with convulsion, very likely it is a case of eclampsia
of pregnancy. It is to be noted that in a patient with repeated
convulsions high blood pressure may not help to diagnose
eclampsia. Similarly, following several episodes of
convulsion the body temperature may rise even without
infection. On the other hand, if the patient was having fever
for some days before the onset of convulsion, it is likely to be
a case of infection of the central nervous system, like
encephalitis. There are many such examples where the
starting complaint becomes decisive.
DURATION OF COMPLAINTS
Often it becomes difficult on the part of the students to clearly
determine the duration of the complaint. However, a general
idea can be made from the mode of presentation. For example,
if a patient says the duration of the complaint is in months
or years, then the onset of the disease is gradual. A patient
complains of abdominal pain for 10-12 months (the range
he tells is 2 months). Similarly, if a patient complains of
dyspnea for 5 to 6 years (the range itself is one year). This
type of presentation suggests chronic nature of the problem
Chief Complaints 43
and gradual onset of the illness. On the other hand, if the
patient is able to tell the exact time and/or date of the onset
of the symptoms it is likely to be an acute illness. For instance,
a patient might say that he felt chest pain on 1st January at
9 am or might complain that he developed weakness of one-
half of the body at 5 am on 1st March.
There are certain illnesses which are by nature episodic,
like epilepsy, bronchial asthma, episodes of congestive heart
failure in cases of existing rheumatic heart disease (RHD),
episodes of acute exacerbations of chronic bronchitis, etc.
To give best information in these situations it will be better
to express as follows:
a. Bronchial asthma
Episodic wheezing 10 years
Severe breathlessness 2 days
b. RHD
Dyspnea on exertion 5 years
Dyspnea at rest 5 days and so on.
In case of chronic illnesses it may be difficult to decide
the exact duration of the illness. Often the patients get used
to live with the problem. They only seek medical attention
when the same symptom becomes severe enough to impair
their way of living or new symptoms get added to it, so that
they fail to do their work. In such situations they say that
the disease has started from the time of their incapacitation.
But truly the disease might have started much earlier. On
tactful asking the true duration of the illness can be
ascertained. Some examples will clarify the issue.
Example 1
A 19-year-old girl came with the complaint of breathlessness
for one month. On examination, she was found to be suffering
from mitral stenosis. Does it mean that the mitral stenosis
has developed within this one month? Obviously not. It
must have started much earlier than this. The true duration
of the illness was revealed in the following way.
Question (Q) by examiner: What are you doing now?
Answer (A) by the patient: Household work.
Q: Why are you not studying?
A: Because of poverty.
Q: From where do you get your drinking water?
A: From the well.
Q: Where is it?
A: It is about half kilometer from my house.
Q: Who brings water for your family?
A: Myself.
Q: What is the size of the pot you are using?
A: About 15 liters capacity.
Q: Are you using the same size pot all the time?
A: Yes.
Q: Are you able to bring the water filled pot to your house
at one stretch?
A: No, I have to take rest once or twice on the way.
Q: Why?
A: Because I feel breathless.
Q: How long you are feeling like this?
A: For last one year.
Here even if the girl is complaining of dyspnea for one
month, truly she is having it for last one year.
Chief Complaints 45
Example 2
A 34-year-old clerk complained of dyspnea for one month,
so that he was not able to go to work. On examination he
was found to have mitral stenosis. Again, does it mean that
his mitral stenosis has developed within one month? It is
not likely. The true duration of the illness was revealed in
the following way.
Q: How far is your office from your house?
A: 2 kilometers.
Q: How do you go to the office?
A: By scooter.
Q: Is your office a multi-storied building?
A: Yes. It is a four storied building.
Q: Is there a lift?
A: No.
Q: In which floor are you working?
A: In ground floor.
Q: How long you are working in the ground floor?
A: For last two years.
Q: Have you ever worked in second or third floor?
A: Yes, two years back I worked in 3rd floor.
Q: Why have preferred to work in the ground floor?
A: Because, I could not go up to 3rd floor.
Q: Why?
A: Because I felt breathless, so I opted to work in ground
floor.
So here again the patient said his illness to be of one
month duration though he had got the problem for two years.
When he was incapacitated by the symptom he consulted
the doctor. Before that he just modified his life style and
went on working, never felt that he has got some physical
problem to seek medical help.
These are just two examples. Everyday we encounter
cases giving ambiguous history, particularly in relation to
the duration of the illness. The true duration can be known
by analyzing work of the patient and how they have been
affected or modified and for how long.
CHAPTER
4
History of
Present Illness
For eliciting any physical finding the

correct method has to be followed. If
the method is wrong, the finding will
be wrong; hence the conclusion will
also be wrong. So practice the correct
method regularly.
INTRODUCTION
History of present illness is nothing but elaborate description
of the chief complaints. Certain points must be told in this
heading are:
• When the patient was apparently normal, when he felt
himself to be ill and what the first complaint was.
• If there is any discrepancy about the onset of the illness
and the timing of coming under medical attention, it
must be clarified.
• What has happened to each complaint, progressed or
regressed (course of the illness).
• Minor complaints which have not been mentioned in
the chief complaints can be discussed here.
• Some negative history.
Sometimes, it becomes difficult to decide from where to
start the present illness if it is there for a long period. If the
disease is not diagnosed earlier and he is not on treatment,
the total illness should be expressed as one. For example,
A case comes with the complaint of dyspnoea at rest for
5 days, palpitation for 5 days, but on enquiry it was revealed
that he is having dyspnea for 5 years. The better way to
express these complaints will be
Dyspnea on exertion—5 years
Dyspnea at rest—5 days
Palpitation—5 days
This will mean that the same disease process has
progressed; possibly he has developed arrhythmia
(palpitation) which has precipitated congestive heart failure
(so dyspnea at rest).
History of Present Illness 49
The same thing can also be expressed while elaborating
the history of present illness. For instance—an established
case of diabetes mellitus for so many years comes with
complaints of:
• Tingling and numbness of both lower limbs 6 months
• Tingling and numbness of both upper limbs 1 month
This will mean that the same disease process has
progressed (a case of diabetes mellitus has now developed
peripheral neuropathy). That he is a case of diabetes mellitus
of so many years duration, on XYZ treatment or no treatment
can be told at the beginning of history of present illness.
On the other hand, if the existing illness does not appear
to have any relationship to the present illness, then the long
standing illness can be mentioned in the history of past
illness. For example, a case of rheumatic heart disease comes
with the complaints of yellow colouration of conjunctiva,
yellow colouration of urine and loss appetite for one week
duration. Here, the patient is possibly suffering from viral
hepatitis which has no relationship to his heart ailment. So
the heart ailment should be mentioned in the past illness.
Similarly, if a diagnosed case of bronchial asthma comes
with hemiplegia of two days duration, then the bronchial
asthma can be included in past illness.
In evaluating the history of present illness there are some
clue points which need elaboration, because they greatly
help in diagnosis. These are:
Circumstances Under Which the Disease Started

Knowing the details of the circumstance under which the
illness started gives valuable clue to the diagnosis in some
cases. A few examples will help to understand this.
• A patient of diabetes mellitus on treatment received the
drugs but took less than the amount of food he is
supposed to take or vomited immediately after intake of
the food. Later on, he was brought in a state of
unconsciousness. Very likely he is suffering from
hypoglycemic coma.
• A patient who had gone to a malaria endemic area and
after few days of returning from the area he suffered
from fever with altered sensorium. He is likely to be
suffering from cerebral malaria.
• A person went to Delhi during the epidemic of dengue
fever and after returning, he suffered from fever with
epistaxis, very likely he has also suffered from dengue.
• An elderly person developed chest pain and collapsed
while running to catch the train. He has most likely
suffered from acute myocardial infarction.
• A case of sub-arachnoid haemorrhage was improving
well until a day when he went to the toilet and strained
for stool. Since then he deteriorated. Very likely he has
had rebleeding.
• A school boy brought unconscious without any
preceding illness and on enquiry it was found that
recently the result of his examination has been declared
and he has failed. It is likely that he has consumed some
poison.
• I remember a patient (a woman) who suddenly started
talking and behaving abnormally from 5 pm of a
particular day. Before that she was completely alright.
That the illness was purely psychogenic was revealed
from the circumstances under which it happened. It was
revealed that a previously finalized marriage proposal
of her daughter was cancelled by the bridegroom. This
message was delivered to her at 5 pm and since then she
started all these symptoms.
• In a hostel, there were two boys in one room. Both of
them used to keep milk in one pot and both of them were
drinking from the same pot. One day the first boy drank
his part of milk and went to play. After some time the
second boy came and while going to drink his share of
milk found that a house lizard has fallen into it. He did
not drink. After two hours the first boy returned and
knew from his friend that there was a house lizard in
the milk. Since then the first boy started vomiting; so
much that it required hospitalization. Here the vomiting
was psychogenic in origin. Had it been due to some
toxic effect, vomiting would have occurred much earlier
and the manifestation would not have waited till
hearing of the news that a lizard had fallen into the
milk.
• A young girl was waiting for a bus at the bus stop on a
hot summer day. After standing under the sun for a
prolonged time she suddenly fainted. This is most likely
due to vaso-vagal syncope.
• In a school a teacher felt weakness, anorexia and nausea.
On investigation it was found that he was suffering from
chronic renal failure. After a few months he died. Soon
after his death, two of his colleagues came for
consultation with exactly similar complaints. Here again
the problem is more of psychogenic rather than real (out
of fear).
• A patient had a fall following which he became
unconscious. Doctors on examination found that he has
developed hemiplegia. Here two things are possible. He
has either fallen down first and sustained head injury
for which he has become unconscious (fall first) or has
developed a stroke for which he fell down and found
unconscious (stroke first). This can be decided taking
the circumstances into account that led to fall. Was the
place slippery where the person fell down? Was it ill
lighted? Was it a known or unknown place? Was the
object over which he stumbled and fell down big
enough? If none is there, there is no reason why should
one fall? So possibly the cerebrovascular accident is first.
Under ordinary circumstances a person with good vision
will not fall down on a known path even in darkness,
unless the path has become slippery or there is something
to stumble over.
Associated Complaints
Often the patient comes with more than one complaint. This
may be told by the patient frankly or may have to be revealed
by tactful questioning. These associated complaints help
us maximum to make the diagnosis. There are many
examples.
Fever
• Associated with cough and expectoration—respiratory
infection
• Associated with jaundice—hepato-biliary disorder,
leptospirosis, complicated malaria. It has to be
remembered that in viral hepatitis by the time jaundice
appears fever subsides.
• Associated with dysuria and frequency—urinary tract
infection.
• Associated with loss of consciousness—CNS infection
(cerebral malaria, meningitis, encephalitis).
Swelling of the Body

• Associated with dyspnea—congestive heart failure,
angioneurotic edema.
• Associated with jaundice—subacute hepatic failure,
decompensated cirrhosis.
• Associated with oliguria and hematuria—acute
glomerulonephritis.
Breathlessness
• Associated with chest pain—pneumothorax, pulmonary
embolism, acute myocardial infarction
• Associated with wheezing—bronchial asthma
• Associated with cough and sputum production—
chronic bronchitis
• Associated with hemoptysis—mitral stenosis,
pulmonary infarction.
Joint Pain
• Associated with morning stiffness—rheumatoid arthritis
• Associated with high fever—septic arthritis
• Associated with chronic diarrhea—inflammatory bowel
disease, and so on.
Negative History
Significant negative history should be told in relevant cases.
For example:
• In an unconscious patient complete absence of fever
practically excludes the possibility of any infective
condition.
• Absence of syncope and angina should be mentioned in
all cases of aortic valve disease, as it is required to assess
the severity of aortic valve disease.
• A patient with convulsion, absence of head injury and
intoxication should be mentioned.
• In a patient with ascending paralysis absence of animal
bite is required to be mentioned. There are many such
negative complaints that are required to be mentioned
in the history of present illness.
CHAPTER
5
History of
Past Illness
When the clinical observation and the

investigation reports go in opposite
direction believe the patient (clinical
findings)
Past illnesses may have a cause and effect relationship with
the present illness or may guide the treatment of the present
illness. In this part of the history, history of similar illness
and history of significant illnesses should be collected.
However, in every case history of hypertension, diabetes
mellitus, tuberculosis and syphilis should be included as
these conditions can affect many organs.
SIMILAR ILLNESS
There are several illnesses which can occur repeatedly
(similar illness). For instances:
• In respiratory system—bronchial asthma, acute
exacerbations of chronic bronchitis, bronchiectasis.
• In nervous system—epileptic attacks, paralytic episodes
of multiple sclerosis, migraine, periodic paralysis,
transient ischemic attacks and so on.
• In cardiovascular system—episodes of congestive heart
failure, paroxysmal supraventricular tachycardia.
• In hematological disorders—hemolytic and aplastic
episodes in congenital hemolytic anemia, bleeding in
hemophilias and others.
• In gastrointestinal system—jaundice, fever and
abdominal pain of cholangitis, active phase of chronic
active hepatitis, active phase of inflammatory bowel
diseases and many more.
SIGNIFICANT ILLNESS
As it may not be easy to decide which past history will be
significant in a particular case, it will be better to ask the
History of Past Illness 57
patient or his relatives to enumerate all the major illnesses
he has suffered from childhood including major accidents
and surgeries. From them one has to screen out which is
important which is not. In this regard the diagnosis given
by the patient need not be accepted. He should be asked to
produce the documents related to previous illness. If he is
not able to do that, ask about the symptoms with their
duration, reports of investigations if at all he is able to
remember or the treatment he received with its duration.
One can grossly know from these verifications what the
past condition was. This is required because often the
patients tell the name of the disease or condition, whatever
they have remembered or understood which may not be
scientifically accurate. For example, if a patient gives history
of rheumatic fever, ascertain it by asking at what age it
occurred, which joints were affected, how severe was the
joint pain, whether there was fleeting character or not,
whether penicillin prophylaxis was advised or not. If a
diagnosis of nephritis is told, ask whether there was
diminished urination or not, whether there was hematuria
or not, whether there was swelling of the face and legs or
not. The methods described to verify the genuine nature of
the complaints can be utilized here also. If he is able to
produce the previous documents go through them and
decide what the past illness was.
There are several significant past conditions and
diseases which have got relationships with the present
illness. With the advancement of knowledge students will
be able to know which past illness is significant in what
conditions. Some examples are given here.
• In a case of heart disease past history of rheumatic fever.
• In a case of amoebic liver abscess history of amoebic
dysentery.
• In a case of tubercular meningitis history of tuberculosis
(often partially treated).
• In a case of infective endocarditis recent history of dental
procedure/urethral manipulation.
• In a case of upper GI bleeding past history of portal
hypertension or acid peptic disease.
• In a case of lung abscess history of unconsciousness or
general anesthesia.
• In case of chronic renal failure history of repeated urinary
tract infection or obstructive uropathy and so on.
HISTORY OF DIABETES MELLITUS

From the symptoms like polyuria, polyphagia and
polydipsia one can suspect about diabetes mellitus. But these
classical features are only found in cases of type I diabetes
mellitus. However in practice majority of the cases being
type II diabetes mellitus, these features may not be found.
Polyuria is due to glycosuria and polydipsia is due to
polyuria (causing volume loss). To have polyuria the blood
glucose level has to go above the renal threshold. So if there
is hyperglycemia of more than 180 mg/dl (renal threshold),
polyuria and polydipsia can be found irrespective of the
type of diabetes mellitus. Even if there may be polyuria and
polydipsia in patients of type-2 diabetes mellitus,
polyphagia is rarely noticed in them. There are many more
symptoms from which diabetes mellitus can be suspected
only. Repeated Staphylococcal skin infection, non-healing
ulcers, repeated balanoposthitis are some of the common
problems from which one can suspect diabetes mellitus.
But these are just guess works. One should always ask for
documented evidence of diabetes. If the patient is able to
produce, go through them carefully and ascertain if the
diagnosis is reliable or not. If he is not able to produce but
he remembers the exact blood sugar level at the time of
diagnosis, this can also be accepted. Also enquire whether
the blood sugar has been tested in a reliable laboratory or
not? Often we see cases that have been diagnosed on the
basis of presence of reducing substances in the urine. This
is not only incorrect, but also dangerous at times. (I have
encountered patients diagnosed as diabetes mellitus on the
basis of urine sugar and have been treated with
hypoglycemic drugs and finally presenting as hypoglycemic
coma. At times the patient shows documentary evidence of
hyperglycemia tested at a previous occasion, but a fresh
report does not support this; the previous report need not be
out rightly rejected. This is possible under certain situations;
like honeymoon phase of type I diabetes, gestational
diabetes, if the patient has developed advanced diabetic
nephropathy, drug induced diabetes, etc.
HISTORY OF TUBERCULOSIS
That the patient was suffering from tuberculosis can be
known from the previous treatment records, X-rays, sputum
examination reports, etc. If such reports are not available,
previous history of prolonged fever, persistent cough (more
than two/three weeks), hemoptysis, weight loss etc (single
or combination) should be enquired. The drugs prescribed
may also help to decide whether these were antitubercular
drugs. Consumption of combipacks, three/four tablets
advised to be taken together in the morning, duration of
treatment for six to nine months; orange color urine after
consumption of the drugs; all may help to decide that it was
an antitubercular regimen. Remember that people often do
not want to reveal that they suffered or are suffering from
tuberculosis and invariably they say that they have
completed the drug therapy even if they have taken for a
few days only.
HISTORY OF HYPERTENSION
In a country like India history of hypertension is obtained
in a confusing manner. Often people (both educated and
uneducated) say that they had/have blood pressure (not
even high blood pressure); which does not carry any
meaning. At times, people say that they are having low blood
pressure. The concept of low blood pressure is also very
vague. Genuine persistent low blood pressure due to an
organic cause is extremely rare. It is also found that people
conclude themselves that they are suffering from
hypertension from the symptoms like reeling of head without
any measurement of blood pressure. If the patients tell like
that without mentioning the correct recording, it should not
be accepted. It is not uncommon to notice that people do not
remember the exact figure of blood pressure and often tell
wrongly. Always emphasis should be given to produce the
documentary evidence of hypertension. At times people are
able to remember the names of the drugs from which it can
be presumed whether the patient was hypertensive or not.
If a normal recording of blood pressure is found at the time
of consultation always ascertain whether the patient is on
the drugs or off the drugs. If they are on the drugs their
blood pressure recording should be mentioned as follows-
BP 130/80 mm of Hg (with A/B/C drugs).
HISTORY OF SYPHILIS
Syphilis in earlier days was the single most important
disease to involve almost all organs. Primarily, it is a sexually
transmitted disease. Unless carefully and tactfully asked
people do not reveal it. In fact most people do not tell freely
about any sexual problems. This is more so in females. To
discuss these matters a suitable environment should be
ensured. The following points are required to be known.
Following the sexual act whether there was any genital sore
or not? In male the commonest site of genital sore is penis
(shaft or glans). In females the commonest site is the cervix.
As it is not possible for the patient to see the cervix, history
of genital sore in females may not be obtained; but does not
exclude syphilis. Whether the sore was painful or painless?
Syphilitic sores are painless. Whether they received any
treatment or not? Because, spirochetes are highly sensitive
to many commonly used antibiotics; a course of antibiotic
may eradicate the infection.
Though syphilis has lost its significance in the post
antibiotic era, another sexually transmitted disease with
multi organ involvement has emerged. That is AIDS. So the
sexual history has not lost its significance even now.
CHAPTER
6
Family
History
The simplest way to improve the

power of observation is to note how
a person differs from a normal man.
Certain diseases are likely to occur in many members of the
family. Presence of similar illness in other members of the
family helps in reaching at a diagnosis. These categories of
illnesses can be divided into two groups.
• Genetically transmitted diseases
• Familial clustering of diseases
GENETICALLY TRANSMITTED DISEASES

There are many diseases which are transmitted genetically.
A family tree should be drawn to know the pattern of
transmission. It is to be kept in mind that a genetically
transmitted condition can occur in a person without similar
illness in the family. This is possible due to mutation. While
analyzing a genetically transmitted condition one has to
keep in mind that a particular condition may not express
completely in all members of the family (full expression or
partial expression). If a genetically transmitted condition is
suspected history of consanguineous marriage in the family
should be enquired. Autosomal recessive disorders are
likely to manifest in such situation. A short list of genetically
transmitted diseases is given herewith.
Autosomal Dominant Disorders

• Adult polycystic kidney disease
• Huntington’s chorea
• Most of the heritable connective tissue disorders like
Marfan’s syndrome, Osteogenesis imperfecta and
others.
• Multiple neurofibromatosis
Family History 65
• Hereditary spherocytosis
• Familial hypercholesterolemia
• Myotonia dystrophica
• Acute intermittent porphyria and so on.
Autosomal Recessive Disorders

• Albinism
• Wilson’s disease
• Sickle cell anemia
• Beta thalassemia
• Cystic fibrosis
• Friedreich’s ataxia
• Hemochromatosis
• Phenylketonuria and homocystinuria and many other
in-born errors of metabolism
X-linked Recessive Disorders

• Hemophilia
• G-6-PD deficiency
• Ocular albinism
• Color blindness
• HGPRT deficiency and others.
X-linked Dominant Disorders (Rare)

• Orofaciodigital syndrome
• Focal dermal hypoplasia
• Incontigentia pigmenti
• Hypophosphatemic rickets
FAMILIAL CLUSTERING OF DISEASES
Some diseases occur in many members of the families due
to exposure to similar environment. Here genetics factors
do not play a role. Genetically dissimilar people can also
suffer from the illness if they stay together. All the members
take food from same kitchen, all take water from the same
pot, all remain in the similar housing condition and all
breathe similar air. So familial clustering of diseases is
mostly
• water borne
• Air borne
• Food mediated.
Food mediated diseases may be due to:

 Germs
 Nutritional deficiency
 Nutritional toxins.
Deficiency diseases are more likely to manifest in them
who require the nutritional factor more, like children,
pregnant women and lactating mothers. Dietary toxins may
be of two types; acute toxins (for instance food poisoning)
and chronic toxins (for instance lathyrism). Acute toxin
mediated diseases are more likely to affect all those who
have consumed the contaminated food, though the dose of
exposure also determines the severity of manifestation.
Chronic toxin mediated diseases are more dependent on
the duration of exposure. As the elder members in a family
are likely to be exposed for longer time, these types of
diseases are more common in them.
CHAPTER
7
Community
History
While examining any patient, take

care of his comfort and privacy.
This is absolutely a new component in history taking, which
has not been described in most other books. In the first
edition of this book I had discussed this part of the history
as the extended family history; however this new name
appears to be more rational. The information that we get
from this part of the history cannot be obtained from other
components of the history. This component of history is
very much useful in reaching at a diagnosis.
Let me first discuss why I felt that this entity is required
to be included in history taking. A case was admitted with
fever, jaundice and unconsciousness. After taking the
history and clinical examination, it was diagnosed to be a
case of complicated malaria (which is very common in this
part of the world in various forms) or a case of hepatic
encephalopathy. While being investigated and treated the
mother of the patient revealed that few more cases of fever
followed by jaundice (similar cases) have occurred in their
locality within last fortnight. This raised the possibility of
an epidemic form of jaundice. Malaria presenting as
epidemics of jaundice is extremely unlikely. This history
revealed by the mother made us think the possibility of the
epidemic form of viral hepatitis. In fact it was proved to be a
case of infective hepatitis. The source of epidemic was also
traced quickly. In this particular case, the case is not
important; the important point is—why we missed the point
in the history, which was later on revealed by the mother.
We missed this point because this part of history does not
come under any components of history taking described in
most of the clinical books (chief complaints, history of
present illness, history of past illness, family history,
Community History 69
personal history, treatment history, menstrual and obstetrics
history). So it appears that the present scheme of history
taking is incomplete. To include this aspect of history I feel
it is required to widen the spectrum of history taking. This
can be named as community history.
In community history, we should try to enquire about
similar illness in the neighbourhood; may be in a locality,
in a hostel or in a camp. This will help us in two ways. First,
it will help us to diagnose the illness of an individual and
start treatment. Second, we can detect an upcoming epidemic
in the community early so that preventive measures can be
taken. So community history will benefit the individual as
well as the community as a whole.
Hence, community history should be included in all
cases as a separate heading in history taking.
CHAPTER
8
Personal
History
Never leave a patient receiving blood

transfusion alone. Basically, it is a
tissue transplant.
Many people have many things personal to them and many
ways of living personal to them. These personal things at
times contribute to the causation of the diseases and so
detection of all these personal things can help in the
diagnosis of the ailments. Though there are many personal
things, few only contribute to the causation of disease and
these things will be discussed here.
FOOD HABIT
• Ask for the type of food one takes, whether he gets two/
three full meals per day or not? What are the usual
contents of his food? From this one can assess whether
one is suffering from malnutrition or not. Remember that
malnutrition related problems rarely occur due to a
single nutritional factor. This will also give idea about
obesity.
• Ask for any liking or disliking for any food. Ask for any
particular reason for the dislike. Dislike for a particular
food may be due to food allergy or intolerance. If history
of food intolerance (wheat products in cases of gluten
enteropathy) or food allergy is found, they should be
advised to avoid such food. Before doing this one should
be sure that it is true; because people often misunderstand
some other problem as a food related problem. Similarly,
if a patient has got an allergic disorder he should be
asked to observe if any particular food exacerbates the
disorder.
• Excess of certain food can cause problems. People taking
excess of coffee may develop reflux oesophagitis. Excess
of tea can produce supraventricular ectopics.
Personal History 73
• Those who are strictly vegetarian (vegan) may suffer
from vitamin-B12 deficiency.
• Frequency and regularity in food intake may be required
to be known for prescription of certain drugs like anti-
diabetic drugs.
• Food related problems may be due to dietary toxins also.
So enquire any such food taken for a long time as happens
with Khesari dal (Lathyrism).
ADDICTION AND HABITUATION

Ask for any type of addiction or dependence. The commonly
encountered agents causing addiction are alcohol, opium,
several drugs, and tobacco in various forms and so on.
Alcohol
Alcohol addiction is the commonest addictions through out
the world. It can cause multiple health problems in addition
to social problems. It can affect the GI system (gastritis,
pancreatitis, fatty liver, hepatitis, cirrhosis of liver), the
nervous system (peripheral neuropathy, Korsakoff’s
psychosis, Wernicke’s encephalopathy, delirium tremens,
cerebellar degeneration, dementia and others). Alcoholics
are more likely to suffer from aspiration pneumonia and
pulmonary tuberculosis. The duration and amount of
alcohol consumption should be enquired. Often people say
that they have left alcohol. But on further enquiry it can be
revealed that they might have left just for a few days only. In
fact history of leaving and resuming alcohol for several times
may be obtained.
Smoking
Ask for the type of smoke one uses (bidi, cigarette, Hucca,
etc.). More important is the amount and the duration of
smoking. Sometimes, people smoke keeping the burning end
inside the mouth. Enquire about the passive smoking too.
Patient might be taking tobacco in other forms also. Enquire
about it because tobacco in any form is bad for health. Some
of the common non-smoking method of tobacco
consumption are brushing the teeth (gudakhu), snuff (nasa),
betel chewing (Pan). There are several problems associated
with smoking.
The Respiratory Problems

Chronic bronchitis, bronchogenic carcinoma, smoker’s
cough.
The Cardiovascular Problems

Coronary artery disease (CAD), peripheral vascular disease
(Buerger’s disease).
Cancers
Smoking is associated with increased incidence of almost
all types of malignancies particularly lungs, oro-pharyngeal
and esophageal malignancy.
Opium
Consumption of opium itself may not cause any ailment,
but it can mask the manifestations of diseases. These patients
are often constipated; their pupil even in physiological state
Personal History 75
may be little constricted. They do not respond to ordinary
doses of analgesics and sedatives.
Drugs
Various types of drugs can lead to habit formation. The
commonly abused drugs are narcotics and benzo-
diazepines. If the drugs are taken intravenously, it increases
the chances of developing infective endocarditis (often right
sided and may be by uncommon organisms) and
glomerulonephritis. In an intoxicated state they are more
prone to suffer from aspiration pneumonia and injuries
(often head injuries). Because of their bad association they
are more likely to suffer from tuberculosis and AIDS.
SLEEP
The habit of sleeping varies from person to person. Ask
when he goes to sleep and when he gets up? Is the sleep
refreshing? Is he habituated to take a nap in the day time? Is
there any recent change in the habit of sleeping? If yes, is
there any obvious cause? For example, following birth of a
newborn often parents have disturbed sleep.
Insomnia
One of the commonest causes of insomnia is presence of
physical ailments and an unfavorable environment. So
always look for any physical illness, particularly a condition
which is painful or causes orthopnea. An anxious or
mentally disturbed person does not go to sleep easily
(induction), gets a light sleep with dreams and often gets up
early and fails to go to sleep again. Some people by nature
take short sleep, but this may be enough for them provided
it keeps them refreshed. Some people go to sleep late and
also get up late. Their biological clock gets tuned to this
pattern, so it does not affect the body or mind provided the
quantity and quality of sleep is normal.
Excessive Sleep
This happens in hypothalamic disorders, Pickwickian
syndrome or under the influence of drugs. Excessive sleep
can also be due to sleep deprivation.
Reversal of Sleep Rhythm

This means night time insomnia and day time somnolence.
This is seen in old age, early stage of hepatic encephalopathy
and nocturnal sleep loss.
BOWEL AND BLADDER

Bowel habits often vary from person to person. Some people
have the habit of defecating once (only in the morning),
some have the habit of going two or three times (all in the
morning), some people have the habit of going once in the
morning and once in the evening. All these are normal.
Because the normal bowel habit is so different, so enquire
about any recent change in the usual habit. Even recent
change in bowel habit may not be significant unless a recent
change in dietary habit and consumption of drugs are
excluded. Pathological cause of recent change in bowel habit
(usually constipation) may be due to colo-rectal malignancy.
Recent onset diarrhea is often due to infection or drugs.
Personal History 77
Bladder habit often differs in physiological state due to
difference in the intake of water and weather conditions.
Women have a tendency to evacuate bladder less frequently
than men. Disturbance in bladder habit may take several
forms like increased frequency of urination, polyuria,
oliguria, hesitancy, urgency, dysuria, incontinence,
retention, etc. Involuntary passage of urine in adult is always
considered as pathological.
SOCIOECONOMIC STATUS
The influence of socioeconomic status on the causation of
diseases is indirect. Poor socioeconomic status leads to poor
housing condition, poor diet and poor hygiene. Hence
various infections, infestations and nutritional deficiency
conditions are more frequently encountered in them. High
socioeconomic status leads to sedentary life-style, intake of
food rich in fat; both causing obesity and the related
problems.
Socioeconomic status is also important for planning the
investigations and treatment. Always attempts should be
made to limit the total expenditure in every case, particularly
in a poor man. For example, a poor man suffers from acute
myeloid leukemia (AML) and comes for treatment. If
scientifically he is planned for treatment, the cost will be so
high that he may have to sell all his property for few courses
of chemotherapy only and ultimately he will die. After his
death his family members will be left to begging. Such cases
should be discouraged for specific treatment. They should
be explained the net consequences of the disease and its
therapy. Under such situation the decision of not treating
the patient is wiser than to treat him. I want to quote one
statement in this regard. Hutchison himself wrote “From
making the cure of the disease more grievous than the
endurance thereof, good lord deliver us.” Under no
circumstances the treatment of an ailment should be more
cumbersome and painful than the disease itself.
Socioeconomic status should be assessed from the total
income of a family and its expenditure. If there is only one
earning member in a family and there are many dependent
members, the socioeconomic status may not be good. On the
other hand if all the members are earning (even if less) then
their socioeconomic status may be fairly good. Assessing
the economic status of salaried people is not difficult. In
farmers economic status should be assessed from how many
acres of landed property they have got and how many crops
they grow and what is the annual yield. In case of daily
laborers things are very obvious. While evaluating the social
status one should try to know about the house (type of house,
type ventilation, lighting), and about the usual sources of
drinking water. Poor housing condition may be contributing
to repeated upper and lower respiratory tract infections,
attacks of bronchial asthma and so on. Unsafe drinking
water may cause several water-borne diseases.
MARITAL STATUS
It is required to know about the marital status of the person
for several reasons. Though marriage itself has nothing
directly to do with any disease, but matrimonial disharmony
is a common cause of psychiatric illness. Physical illness in
a spouse may be a cause of the matrimonial disharmony
Personal History 79
(often the illness may be trivial). Often one spouse may get
frightened at the illness of the other spouse. Here they should
be clearly explained about the nature of the illness and the
modalities of treatment. Even they can be advised how to
adjust with each other in day to day life. If one partner
becomes Hepatitis B positive, the other partner should be
immediately vaccinated.
If somebody becomes father at an advanced age the child
may develop Marfan’s syndrome and if somebody becomes
mother at an advanced age the child may suffer from Down’s
syndrome. Because diabetics can develop impotence later
on in the course of the illness, they are to be advised to
complete the family earlier. There are some conditions like
Eisenmenger’s syndrome, tetralogy of fallot, co-arctation of
the aorta, primary pulmonary hypertension, where the
woman is advised to avoid pregnancy; because these women
do not tolerate pregnancy and delivery well. If there is a
chronic illness in the parents (not necessarily genetically
transmitted disease), often they ask if the illness is likely to
occur in their children. Things should be clearly revealed
and explained to them. If it is a genetically transmitted
condition it should also be told what the probability of the
offspring developing the disease is and how it can be
detected before birth if possible.
In all married individuals enquire about the number of
children and their health. Infertile couples often come with
various psychosomatic illnesses.
EXERCISE
Ask if the patient does some physical exercise (includes
physical work) or not. Note how he is tolerating the exercise.
Whether he has stopped or modified the exercise; if so is
there any specific reason. If he is habituated to do some
physical exercise it is required to instruct him (even if not
asked) if he can do the same after some major illnesses
particularly cardiovascular and respiratory illnesses; if so
what is the ideal time? Patients of coronary artery disease
and subarachnoid hemorrhage should avoid isometric
exercise.
PETS
Many people keep various types of pets. If the patient keeps
one enquire about it. Whether proper care is taken or not?
Whether properly vaccinated or not? Bird droppings can
precipitate asthmatic attack, bird handlers can suffer from
ornithosis. Keeping unvaccinated dogs or cats may lead to
bites or scratches which can lead to rabies, unhealthy dogs
can transmit hydatid disease.
CHAPTER
9
Menstrual
and Obstetric
History
The absolute Sciences in Medicine are

Anatomy, Physiology and Bio-
chemistry. Learn clinical medicine
keeping them in the background.
Irrespective of the type of illness (medical, surgical or
gynecological) menstrual and obstetric history should be
taken in every female patient particularly in the child
bearing age group. The age of menarche and menopause
should be ascertained and details of the menstrual cycles
should be taken.
Usually menarche occurs between the ages of 12 to
14 years. If it does not occur by 20 years of age it should be
called as delayed menarche, which may be due to various
local and systemic diseases. Menarche before the age of 8
years is called precocious puberty which may be due to
certain brain tumors, hormone secreting ovarian tumors,
hypothyroidism, postmeningitic and encephalitic state.
Similarly menopause commonly occurs between 45 to
55 years (mean age 47 years). When it occurs before 40 years
it is called premature menopause. This might be due to
pituitary disorders or ovarian failure. Delayed menopause
may be due to conditions like endometrial carcinoma and
uterine fibroid. There can be various menstrual irregularities
towards menopause. But all irregularities are not
physiological. The ways menopause comes are:
• Gradual lengthening of the cycles, a few cycles may be
completely missed
• Gradual decrease in the amount of blood loss
• Both of the above
• Abrupt stoppage of menstrual cycles.
A normal menstrual cycle indicates that the pituitary,
ovarian and uterine axis is completely normal. Normal
menstrual cycle has got two parts; the cycles and the flow
period. The length of the cycle varies from 25 to 30 days
Menstrual and Obstetric History 83
with a mean of 28 days. The average duration of flow varies
from 3 to 5 days and the amount is between
50 ml to 200 ml. Normal menstrual blood does not clot.
Passage of clots usually signifies excess flow. Flow more
than 8 days also indicates excess flow (menorrhagia).
Menorrhagia ordinarily suggests local disease in the uterus
like fibroid, genital tuberculosis, endometriosis,
adenomyosis etc, but can be due to systemic illnesses like
bleeding disorders, hypothyroid state and so on. Scanty
menstruation is also a common complaint. Here the
duration of menstrual flow is one or two days only. If the
cycles are regular this alone does not cause any problem,
hence needs only reassurance. However, if it is associated
with irregular/infrequent menstrual cycles, ovarian failure/
sub function should be thought of. Disorder in the cycle
signifies defect in the pituitary ovarian axis and disorders
of flow suggests defect in the uterus.
Some of the common disorders of cycle are poly-
menorrhea and metrorrhagia. In polymenorrhea the length
of the cycle is shortened to two to three weeks. It may be
associated with excess bleeding during the flow; when it is
called polymenorrhagia. These types of problems are
encountered at menarche, menopause and few cycles
following delivery. Metrorrhagia means there is irregular
acyclical bleeding; there is bleeding in between the normal
cycles. Mostly this type of abnormality is found in genital
malignancies (uterine/cervical/vaginal); but may be due
to submucous fibroid, uterine polyp and cervical polyp.
The commonest cause of amenorrhea in child bearing
age group is pregnancy. So in every case of amenorrhea in
this age group pregnancy must be excluded irrespective of
the marital status. In fact family members do not accept
pregnancy in an unmarried girl or widows. While revealing
such fact one should be tactful. This has put many doctors
in awkward position. Besides pregnancy there are several
systemic diseases which can lead to amenorrhea like
thyrotoxicosis, advanced genital tuberculosis, Sheehan’s
syndrome, consumption of oral contraceptive pills,
prolonged intake of tranquilizers, Addison’s disease,
adrenal tumors, long standing diabetes mellitus, anemia,
chronic renal diseases and so on.
Women very often do not speak out freely about their
genital problems including the menstrual problems. So it is
better to ask directly certain questions related to menstrual
cycles and genital discharge. This often helps to pick up
cases of carcinoma cervix early. Often women complain of
weakness, reeling of head (vague complaints) even if their
primary problem is leucorrhea.
Pregnancy must be excluded in every female case of
reproductive age group because investigations (particularly
radiological) should be done judiciously. Prescribing for
pregnant woman needs special precaution also. These
restrictions are more important if it is early pregnancy. Some
general guidelines for prescribing in pregnancy are:
• Avoid all drugs as far as possible.
• Prescribe those drugs which has been declared to be
safe.
• The dose and duration should not exceed that is
compatible with achieving the therapeutic goal.
Menstrual and Obstetric History 85
• If decided to prescribe a drug which has not been
declared safe, the patient and the guardians should be
informed and explained the necessity of such
prescription.
• If the drug or the procedure is likely to be too hazardous,
termination of pregnancy can be advised.
It may so happen that a woman has conceived in the
continuing cycle so that there is no history of amenorrhea.
For example, a woman had last menstrual period (LMP) on
1st April. She comes for consultation for some other illness
on 25th April. There is no amenorrhea yet. But her ovulation
is supposed to have occurred around 14th of the same month
(thinking it to be a 28 days cycle) and if she has conceived
around that time she might be carrying a pregnancy of
8 to 10 days duration at the time of her consultation.
Exposure to radiation or to any potentially harmful drugs
during this highly vulnerable period should be avoided. To
avoid such cases the rule of ten days should be obeyed. The
first ten days from the day of menstruation is the safest
period for any investigation or for any treatment. Grossly, it
can be told that the first half of the cycle is safe and the
second half is unsafe.
Menstrual history is not only important for medical
illnesses but also needed for surgical conditions. For
instance—a rupture ectopic pregnancy or a red degeneration
of the fibroid can be confused with other acute abdominal
conditions.
Obstetrics history is equally important to assess the
severity of a long-standing illness; often may help to decide
the exact duration of the illness (how the previous
pregnancies have been tolerated). Repeated stillbirth and
abortion may be due to some underlying illnesses. Whether
the present pregnancy is valuable or not can be known from
the obstetrics history and accordingly treatment can be
planned. Other medical illnesses related to child birth are
cortical venous sinus thrombosis, peripartum cardio-
myopathy, etc.
CHAPTER
10
Treatment
History
A patient developing a new

complaint while on treatment,
attribute it to the drugs rather than
to the disease.
History of medical and surgical treatment should be
obtained from all patients. When ever possible ask to
produce the records of previous treatments and operations.
This is required because previous treatments might be having
direct bearing with the present illness. For example,
• If a case has received chloromycetin earlier and now
comes with hypoplastic anemia, it may be causally
related.
• If a patient had gastrectomy earlier and now comes with
anemia he might have developed megaloblastic anemia
due to deficiency of vitamin B12.
There are many such examples.
Even treatment received for the present illness should be
known clearly. The signs and symptoms of the present illness
may get modified because of treatment. For example,
• If a case has received antipyretics recently he may not
have fever at the time of examination.
• If a case of diabetes mellitus is on antidiabetic drugs he
may not have symptoms of diabetes; even his blood
sugar may be normal (but does not exclude diabetes).
• If a case of hypertension is on antihypertensive drugs
his present blood pressure measurement may be normal
(does not exclude hypertension).
• If a case is getting beta-blocker his resting heart rate may
be slower.
• If a case is getting parasympatholytic drugs his pupil
may be little dilated.
So if you are examining a case who is receiving some
form of medication, always due consideration should be
given to their effect on the existing disease process.
Treatment History 89
Details of treatment are also required for other purposes.
• If a patient is on treatment with certain drugs, before
declaring that the drug is not effective one should be
sure that the drug has been taken in adequate dose and
for adequate duration.
• On the contrary if the drug has been taken adequately
(dose and duration) and the patient has not shown
satisfactory response there is no meaning of continuing
the same drugs. He might require change of the drugs or
addition of some other drugs. At times continuation of
certain drugs without knowing how long he is
continuing the drugs may lead to toxic effects,
particularly the drugs which have low therapeutic
window (digoxin, anticoagulants).
• There are some drugs which are to be continued for a
long time like drugs for bronchial asthma, drugs for heart
failure, antiepileptic drugs, antianginal drugs and
others. Abrupt withdrawal of these drugs may lead to
exacerbation of the underlying illness, at times may result
in fatal outcome. Abrupt withdrawal of gluco-
corticosteroids after a prolonged course may cause acute
adrenal failure. Abrupt withdrawal of beta-blocker in a
patient of coronary heart disease may precipitate acute
myocardial infarction. Hence unless contraindicated
these drugs have to be continued irrespective of the type
of present illness.
• While taking the treatment history do not rely on the
name of the drugs told by the patients, because often
they do not tell them correctly. So always try to see the
prescription and try to physically verify the drugs if he
is having with him. Even if the drugs have been
prescribed and dispensed correctly, often patients take
them in a confusing manner (particularly illiterate
people). This happens mostly if there are many medicines
in the prescription. At times patients themselves modify
the dose giving various explanations. All these aspects
are to be looked for in the evaluation of the treatment
history.
• If a patient develops any major adverse drug reaction to
any particular drug (for example anaphylaxis or
exfoliative dermatitis); a written warning card (if possible
laminated) should be issued to him with the instruction
to carry it with him all the time and to produce it before
all doctors for any future consultation.
• In case of infants it may be required to know the
medications the mother received during pregnancy and
lactation.
All doctors are supposed to give the details of the
treatment at the time of discharge or referral. Even
presumptive treatment, therapeutic trial, etc. should be
mentioned to avoid confusion later on. These things are
very important in referral hospitals because rarely they get
virgin cases. It becomes easy to follow up such cases by
other doctors.
Often students do the mistake of seeing the referral slip
before evaluating the case themselves. This is likely to
misguide them. By going through the treatment papers they
often jump to a conclusion which may be wrong. This
practice blunts the development of their thought process
and judgment power. Rather they should take thorough
history and do detail examination, come to a conclusion
and later on they can verify with the treatment papers or
referral slip as the case may be.
CHAPTER
11
History in
Cases of Fever
One must teach to maintain the flow

of knowledge, if possible by research
one should try to add to the existing
pool of knowledge; but one should
never allow the level of knowledge to
decline. This is expected from every
teacher and student.
Possibly fever is the second most common complaint next
to pain in clinical practice. There are many causes of fever.
So the approach to the cases of fever should be rational to
plan the investigations and reaching at a correct diagnosis.
Unless done so, diagnosis is often delayed, which may lead
to death. Many patients have died or diagnosed late because
of incorrect approach. In most of these cases death has been
because of underestimating the value of history. If we will
depend too much on investigations and neglect the proper
clinical evaluation of cases this will happen everywhere.
Investigations always may not be informative, may also
mislead us. In comparison to pain, fever is better quantitated.
An ordinary clinical thermometer is enough for this purpose.
Now let us see how to approach a case of fever.
IS THE COMPLAINT GENUINE?

Whether the complaint of fever is genuine or not can be
ascertained by recording the temperature. Either the doctor
himself can record the temperature or can ask the family
members to record the temperature and make a chart.
Remember that don’t leave this work to the patient himself.
If he wants to take some advantage of fever he may produce
a false temperature record. If the thermometer shows that
the body temperature is elevated not only it shows that the
patient is febrile, but also he is genuinely ill (has organic
illness). Because, it is not easy to raise the body temperature
artificially and body temperature is not elevated in
physiological conditions. It is to be warned that the body
temperature should not be assessed just by touching the
History in Cases of Fever 93
body with fingers as done at times by the students. Very
often a wrong impression is made by doing so. Often young
woman come with the complaint of fever for several days,
but there is no other associated complaints nor there is any
effect on the body (maintain good health). In such situations
ask the family members to maintain a temperature record at
least every six hourly and at the time of feeling maximum
fever. Just such an advice often cures the fever of these
persons. Sometimes people complain of a sense of fever
(feverishness) without true elevation of body temperature.
Such feeling is often observed in situations of peripheral
vasodilatation like thyrotoxicosis, use of vasodilator drugs
like nifedipine, in the prodromal stage of infective fevers
and in postmenopausal stage. Unless there is recorded fever
there is no need of investigating such cases.
INFECTIVE FEVER OR NON-INFECTIVE FEVER?

Once it is seen that patient has got genuine fever one should
try to know whether it is due an infective cause or due to a
non-infective cause. Different types of infections are by far
the commonest cause of fever.
Infective Fevers
Infection may be due to bacteria, fungi, parasites or viruses.
Infection might be in the blood (bacterimia, viraemia,
parasitemia) or in any particular system like urinary system,
respiratory system, nervous system, gastrointestinal system,
etc. One can suspect that it is an infective fever from the
following features:
Abrupt Onset of Fever
An otherwise normal man if develops fever suddenly an
infective cause should be thought of. In case of heat stroke
body temperature may rise suddenly, but there will be history
of exposure to strong sunshine.
If Associated with Prodromal Symptoms

Headache, anorexia, myalgia. malaise, nausea are some of
the common prodromal symptoms. These features might be
present in non-infective fevers also as in lymphomas. But in
infective cause it will be of short duration, in case of non-
infective etiology it will be of long duration.
If Associated with Chill and Rigor

If fever is associated with chill and rigor it is likely to be
infective fever. Some infective causes of fever where chill
and rigor are commonly seen are upper urinary tract
infection, cholangitis, abscess formation, malaria and filaria.
A single shaking chill at the beginning is possible in
pneumonia.
If it is High Fever
If the fever is high (>104°F) often it is infective in origin.
Heat stroke is an exception. In spite of being a non-infective
cause the temperature here may be very high. The other
non-infective condition where fever can be high is pontine
hemorrhage. But here fever is not the chief complaint; loss
of consciousness is the major complaint and the starting
complaint.
Associated with Systemic Manifestations
Along with fever there will be other symptoms related to the
organ system involved.
For example,
• Cough, expectoration, chest pain, hemoptysis—
respiratory system
• Dysuria, frequency, loin pain—urinary system
• Head ache, vomiting, convulsion, loss of
consciousness—CNS
• Diarrhea, abdominal pain, vomiting—GI system
In the absence of systemic features possibly the cause of
infection is in the blood itself. It may be viremia (viral fevers),
parasitemia (malaria), Bacterimia (typhoid fever). To start
with there may not be any systemic features in these
conditions, but when the infection get more localized to any
particular organ, symptoms related to that organ may
develop. For example, to start with there may be only fever
in malaria, but when it involves the brain, loss of
consciousness and convulsion can occur. Initially there may
be fever with other prodromal features. At this stage it may
not be easy to know the cause of fever. But when jaundice
appears one can know that it is viral hepatitis and the fever
was due to viremia.
Non-infective Fevers
The non-infective causes of fever are not uncommon. They
may present as fevers of short duration and fevers of long
duration.
Fevers of Short Duration
These may be confused with fevers of infective origin. Some
of the causes such fevers are:
Tissue necrosis: Pulmonary infarction and myocardial
infarction. In these conditions rarely fever is high and it is
not the starting complaint of these conditions. Other
complaints dominate the clinical setting.
Internal hemorrhage: Gastro intestinal bleeding, cerebral
parenchymal bleeding, subarachnoid hemorrhage. In these
conditions also fever is not the starting complaint. Though
fever is mostly low grade, but there can be hyperpyrexia in
pontine hemorrhage.
Immunological inflammations: Drug reactions, blood
transfusion reactions, allergic reaction to intravenous fluids
are common such causes. Acute rheumatic fever is also one
such cause. Fever following vaccination also comes under
this group.
Toxins due to bites and stings can also cause fever in the absence
of infection as seen in snake-bite, bee sting and so on. In
these situations often the cause is obvious, but at times it
can be confusing due to superadded infection. If the fever
starts within six hours of the incidence possibly it is due to
the toxins, if later it could be either. High fever and high
TLC (> 15000/cmm) will go in favor of infection.
Fevers of Long Duration

Fevers can last for several days or months due to non-
infective causes. In fact these are the more common causes
of fevers of long duration in many communities. Some of
them are:
Collagen diseases: Systemic lupus erythmatosus, vasculitis,
Wagener’s granulomatosis and rheumatoid arthritis are
some of the causes. Detail history and physical examination
will very often provide the diagnostic clue.
Sarcoidosis: This is a relatively uncommon cause. Often it is
diagnosed by exclusion.
Lymphoreticular malignancies: Lymphomas and Leukaemias
are the common causes of fever of long duration. Ordinarily
fever is of low grade. It is not necessary to have fever
continuously. Afebrile period may be there in between the
periods of fever. Superimposed infection might contribute
to fever also. Associated symptoms like swellings in axilla,
groin, neck (lymph node enlargement), abdominal swellings
(liver and spleen enlargement), bleeding tendency, bone and
joint pain are some of the common associated complaints.
Solid tumors like hypernephroma, hepatoma, ovarian tumors,
bronchogenic carcinoma, etc. are common solid
malignancies, which can cause fever. Unless other obvious
symptoms of the condition exist it may be difficult to suspect
these cases clinically. In conditions like bronchogenic
carcinomas fever might be due to superadded infection
distal to the lesion.
DIAGNOSTIC CLUES IN A CASE OF FEVER

In a case of fever the following points which help in the
diagnosis are to be collected in history.
Duration of Fever
All fevers to start with are of short duration. If fever persists
for more than three weeks without detection of a specific
cause and if it does not respond to treatment given on the
basis of available information then it can be told as fever of
long duration. These are the cases of so called pyrexia of
uncertain origin.
As enumerated above both infective and non-infective
illnesses can cause fever either of short duration or of long
duration. Most of the infective causes come under the fevers
of short duration. Some of the common infective causes of
long duration fevers are tuberculosis, malaria, AIDS, kala-
azar, brucellosis, infective endocarditis, amoebic liver
abscess. Of these in a country like India by far the commonest
cause of long duration fever of infective origin is tuberculosis
with or without AIDS. So it is told that no case of pyrexia of
unknown etiology should be allowed to die without a trial
of antitubercular drugs. Typhoid is a common cause of fever
in tropical countries, but hardly it lasts beyond one month.
On the other hand, the common causes of fever which
last for a long duration are non-infective in origin.
Prevalence of the Febrile Illness in a Particular Locality

While treating a case of fever one should first think of a
condition which is prevalent in the locality. Common
diseases with atypical manifestations occur more commonly
than the uncommon diseases. In a malaria endemic zone
one should suspect malaria as the common cause of fever
even if it does manifest with typical features. Similarly, with
kala-azar, tuberculosis and others. There is no reason of
thinking the cause of fever as yellow fever in countries where
it is not seen at all, as in India. In some countries tuberculosis
is a less common cause of fever than fungal infections. In
such countries one need not think of tuberculosis as the
cause of fever unless there are definite evidences for it. This
is important because one can start presumptive treatment
till a definite diagnosis is made.
History of Recent Travel

If a febrile illness starts immediately after returning from a
place where a particular disease is endemic/epidemic then
that illness should be the possible diagnosis. In fact such
illnesses can be quite severe in these persons as they might
not be having the immunity against the infection. This may
be within a country or outside a country.
History of Epidemic
If there is an epidemic in a particular area, the new cases
presenting with similar complaints in that area should be
thought of suffering from the same disease. A person going
to that area and suffers from similar illness while staying in
the area or soon after returning from the area, he should
also be thought of suffering from the epidemic disease. For
example, if a patient suffers from fever with bleeding from
multiple sites while staying at Delhi or soon after returning
from Delhi during the Dengue epidemic, possibly he is also
suffering from Dengue fever.
Associated Complaints
Out of all points this is the most important point to make a
diagnosis. Let us see how they help.
Fever with loss of consciousness: Complicated malaria,
meningitis, encephalitis, typhoid encephalopathy are the
common causes. It should be remembered that in all these
conditions fever is the starting complaint. There can be fever
in unconscious patients due to other causes which do not
come under this heading. In these cases unconsciousness
is first, fever occurs later on. Some examples are
subarachnoid hemorrhage, cerebral hemorrhage, pontine
hemorrhage or if the patient develops secondary infection.
Aspiration pneumonia is fairly common in unconscious
patients. In complicated malaria, bacterial meningitis, viral
meningitis and encephalitis, fever is usually of short
duration. But in tubercular meningitis and in typhoid
encephalopathy often the fever is of longer duration.
Typhoid encephalopathy occurs after two to three weeks of
the onset of fever. Enteric encephalopathy is rarely
encountered these days. Headache is more marked in
bacterial meningitis than in cerebral malaria. Convulsion
is more marked in encephalitis though it can occur in other
conditions also. Abnormal movements, oculogyric crisis,
excessive salivation, changes in the muscle tone
(hypertonia) are some special features in encephalitis. In
brain abscess there may not be fever and the patient may
not be unconscious. Focal convulsion and focal neurological
deficit are more common in this situation.
There could be focal neurological deficit in all these
conditions. The common neurological deficits are cranial
nerve palsies, hemiplegia, involuntary movements, ataxia,
mental abnormalities and changes in muscle tone.
Fever with chill and rigor: The common causes of fever with
chill and rigor are malaria, filaria, cholangitis, urinary tract
infection particularly upper urinary tract infection
(pyelonephritis). A single chill at the beginning of fever is
possible in pneumonia. Repeated chill and rigor within
24 hours is suggestive of suppuration. Ordinarily a case of
pneumonia does not develop chill except at the onset. But
with the development of lung abscess or empyema he can
develop repeated chill. Repeated chill with wide variation
of body temperature (>5°C) often suggests pus formation
(suppuration). But if the examination does not reveal pus
anywhere, possibly pus is inside the abdomen, either in the
sub-diaphragmatic space or in the pelvis. It has to be
remembered that if the patient takes frequent antipyretics
he can suffer from several episodes of fever with chill and
rigor.
Fever with jaundice: Such a combination of symptoms is
possible in viral hepatitis, malaria, leptospirosis, yellow
fever, and cholangitis. Usually in hepatitis by the time
jaundice appears fever subsides. In cholangitis often
abdominal pain is a conspicuous complaint and often it is
associated with chill.
Fever with bleeding: Fever with bleeding from nose can be
seen in acute rheumatic fever and typhoid fever. But fever
with bleeding from multiple sites can be due to acute
leukemia, infection in cases of hypoplastic anemia and
thrombocytopenia. Dengue fever and leptospirosis are other
febrile conditions where bleeding from multiple sites can
occur. It has to be kept in mind that if there is only upper
gastrointestinal bleeding it may not suggest a systemic
problem. It could be due to consumption of NSAIDs causing
erosive gastritis. Often people consume these drugs to get
relief from pain and fever, even without prescription.
Bleeding from a particular organ can be due to disease in
that organ. For example, hemoptysis in respiratory disease,
hematochezia in intestinal disorder like typhoid fever,
hematuria in urinary tract infection, renal tuberculosis and
hypernephroma.
Fever with arthritis: Arthralgia is fairly common in several
febrile conditions. But true swelling of joints with pain occurs
in acute rheumatic fever (fleeting polyarthritis, big joints,
age between 5 to 15 years), septic arthritis (usually single
joint, red, very painful), SLE and other collagen diseases.
Acute leukemia in children can produce a state like that of
acute rheumatic fever. In acute gout there can be fever also.
Fever with arthritis is also seen in chikungunya, a viral
infection. In chikungunya many joints may be affected;
mostly lower limb joints are affected. In this condition fever
is short lasting but joint pain and swelling may last for
several days.
Fever with skin rashes: There are few febrile conditions where
one can get cutaneous rashes. In chicken pox one can get
macular, papular, vesicular and pustular rashes. All forms
might be present at one particular phase of the illness. In
measles rashes are maculo- papular, similar rashes are also
found in German measles though less severe. Measles rashes
do not appear over sole and palm. Rashes of German
measles have a tendency to descend downwards from
hairline and they may be pruritic. Many other viral illnesses
can cause maculo papular rashes like ebstein barr, echo,
coxsackie’s, HIV and dengue. In typhoid fever macular red-
colored rashes (rose spots) are found in the second or third
week of fever mostly over the chest or abdomen. It is difficult
to see in dark-skinned individuals. In typhus similar rashes
occur but they appear earlier than in typhoid and at times
they can be hemorrhagic. In meningococcal infections also
skin rashes can be seen. These are mostly petechial or
purpuric in nature. In disseminated gonococcal infection
there can be purpuric rashes mostly over joints. A typical
skin lesion is seen in cases of staphylococcal scalded skin
syndrome where large areas over skin become erythematous,
often the skin is tendered. Spreading erythematous lesions
over trunk are seen in cases of acute rheumatic fever.
Whatever rashes one gets in a febrile illness always it may
not be due to the disease itself. It could be due to some drug
allergy too. If the rashes do not fit to the disease concerned,
if the rashes are pruritic and if the patient has received some
offending drugs then it is better to think of a drug rash.
Specific facial rashes (malar rashes) may be found in cases
of SLE.
Fever with abdominal pain: Though fever is seen in many
acute abdominal conditions, hardly in any of them fever is
the starting complaint. Abdominal pain, vomiting are the
dominant complaints in these conditions. Some such
conditions are acute pancreatitis, acute cholecystitis and
acute appendicitis. However, hepatitis and amoebic liver
abscess may present as fever with abdominal pain. In both
the situations fever is rarely high grade; pain is hardly severe.
Fever with cough/chest pain: Fever with cough is seen in
respiratory infections. If associated with sputum production
it suggests inflammation in the respiratory tract or in the
lung parenchyma. Lung parenchyma inflammation
(pneumonia) produces high fever where as bronchial tree
inflammation (bronchitis) either does not cause fever or it is
of low grade. Inflammation of pleura does not cause sputum
production and but causes pleuritic chest pain (details
described in respiratory system).
Fever with urinary symptoms: Urinary tract infection has been
divided into upper urinary tract infection (pyelonephritis)
and lower urinary tract infection (cystourethritis). In lower
urinary tract infection fever need not be high which is
noticed in pyelonephritis. Dysuria, frequency, urgency may
be found in cystourethritis, not in pyelonephritis. Loin pain
is a marked feature of upper urinary tract infection, but dull
aching pain in the suprapubic region may be felt in cystitis.
Fever Pattern
Often the pattern of fever helps to know the cause. To know
the pattern of fever one has to record temperature at least
every four hourly and should be recorded for a few days.
This often becomes impracticable. Consumption of
antipyretic drugs alters the fever pattern. Consumption of
antipyretics is so common that making a diagnosis of the
cause from the pattern of fever has practically become
impossible. However, a correctly recorded temperature chart
certainly helps to know the response to treatment. Let us see
some commonly observed fever patterns.
Continued: Here fever persists throughout twenty-four hours
(does not touch the base line) but the diurnal variation is
within 1°C (1.5°F). Causes are typhoid and typhus fever.
Remittent: Here also the temperature does not touch the base
line through out 24 hours, but the diurnal variation is more
than 2°C(3°F). Most of the febrile conditions seen in clinical
practice come under this pattern.
Intermittent: Here temperature touches the base line within
twenty-four hours. Depending on the spikes of fever in
relation to time this type of fever has been subdivided into
the following types.
a. Quotidian: Fever spike comes daily.
b. Tertian: Fever spike comes once in two days.
c. Quartan: Fever spike comes once in three days.
All these types of fever are commonly seen in
malaria. However, these types of fever may not be seen
in the first week of the onset of fever and in falciparum
malaria it may not develop at all.
d. Double quotidian: Two spikes within 24 hours, seen in
kala-azar.
e. Hectic: Several spikes of fever may come within a day.
There will be wide fluctuation of temperature, may range
more than 5°C. The fever may go to hyperpyrexic range
(>107°C) and at the other time may go to hypothermic
range (<95°C). This type of fever is often called as septic
fever or hectic fever, found in septic conditions
(suppuration some where).
Very high fever (hyperpyrexia): When the temperature is more
than 107°F (41.6°C) it is called hyperpyrexia. Conditions
like malaria, heat stroke, encephalitis, pontine hemorrhage,
pituitary apoplexy can produce such a high temperature.
Rare varieties of fevers: There could be fever in episodes. Febrile
and Afebrile episodes occur alternately at variable intervals.
Episodes are often repeated at an interval of two weeks in
Pel-Ebstein fever seen in Hodgkin’s lymphoma. Not so
regular episodes of high fever are seen in relapsing fever
due to Borellia infection.
Time of Onset of Fever

Often the time of onset of fever helps in diagnosis. If the
patient says the onset in days possibly it is of acute onset, if
he says in weeks or months it is a chronic illness. In
pneumonia often the patient remembers the exact time of
onset of fever.
Degree of Fever
It is difficult to know accurately the degree of temperature
from history only. Recoding with the help of a thermometer
is necessary. However it is possible to know from the words
people use to describe the fever. Fever is low grade if it is
upto 101°F, from 101 to 104°F is moderate grade and above
104°F is high grade. Febrile response is higher in children
than in elderly individuals. The grade of fever often helps to
exclude certain conditions. For example in subarachnoid
hemorrhage it is not high, in compassion to bacterial
meningitis where it is high. Clinically both may behave
similarly. High-grade fever is more often infective in origin.
High-grade fever should be brought down by tepid sponging
or by antipyretics as it can cause febrile convulsion in
children; it can cause delirium and increases the
cardiovascular burden due to increased heart-rate in adult.
CHAPTER
12
History in
Cardiovascular
Disorders
In relation to treating diarrhea with
dehydration, the basic difference
between a general doctor and a
specialist doctor is, the latter knows
when to stop the intravenous fluid.
The components of a cardiovascular diagnosis are:
• Etiological like congenital, rheumatic, coronary,
syphilitic, etc.
• Anatomical (structural) like mitral stenosis, aortic
regurgitation, etc.
• Hemodynamic effects (like pulmonary arterial hyper-
tension, congestive cardiac failure).
• Specific complications (like infective endocarditis,
arrhythmia).
• Functional status (expressed as NYHA class).
Many of these aspects can be known from a carefully
taken history. In the history the following points as described
below are to be collected.
THE CHIEF COMPLAINTS

The patients with cardiovascular problems commonly
present before the physician with the following chief
complaints either single or in combination.
• Dyspnea
• Swelling of the body
• Chest pain
• Syncope
• Palpitation
• Hemoptysis
• Fever
• Neurological deficit
• Repeated respiratory infection
Of these the first six are more important.
History in Cardiovascular Disorders 109
HISTORY OF PRESENT ILLNESS
Dyspnea
People express dyspnea by several words like
breathlessness, shortness of breath, not getting enough air,
etc. In addition to diseases of the CVS dyspnea may be due
to respiratory cause or may be due to anemia also. Though
all dyspnea increases on exertion, but this is more often
seen in cardiovascular conditions. Dyspnea due to
cardiovascular problems indicates the disease is in the left
side of the heart (aorta, aortic valve, left ventricle, mitral
valve and rarely left atrium).The basic mechanism of
dyspnea in cardiovascular disorders is decreased lung
compliance. More energy is spent to take the required tidal
volume (increased work of breathing). This is due to
pulmonary venous congestion which is the effect of elevated
left atrial pressure. In the absence of organic obstruction of
the mitral valve elevated left atrial pressure indicates
elevated left ventricular end-diastolic pressure, which
happens only with the onset of left ventricular dysfunction.
Hence, dyspnea in cardiovascular diseases indicates left
ventricular or left atrial failure. Dyspnea is not a symptom
of the disease in the right side of the heart, where pulmonary
circulation is under loaded. In fact the severity of dyspnea
in patients with left ventricular dysfunction decreases with
the onset of right-sided heart failure.
Severity of dyspnea should be categorized into NYHA
class. The mildest one is Class I and the most severe one is
the Class IV. If the dyspnea is solely due to the severity of
the underlying heart disease it will gradually progress from
Class I to Class IV (I > II > III > IV). But at times we encounter
cases where the severity of dyspnea jumps one or two steps.
For example a case can go from Class I to Class IV bypassing
II and III. Whenever such a history is obtained one should
try to find out a precipitating cause (onset of arrhythmia,
infective endocarditis, fresh attack of rheumatic carditis,
withdrawal of anti-failure drugs, systemic infection
particularly respiratory infection, etc.). In such cases as soon
as the precipitating factor is controlled the patient will go
back to the original NYHA Class.
Variants of dyspnea are paroxysmal nocturnal dyspnea
(PND) and orthopnea. PND typically occurs two to three
hours after actual sleep. If the patient goes into actual sleep
for about three hours even in day time, he can develop PND;
whereas if he does not go to actual sleep even in night time
he may not develop PND. Hence the nocturnal is truly
misnomer. PND is nothing but a miniature pulmonary
edema and indicates more severe pulmonary venous
hypertension.
As the disease (left-sided heart disease, hence the
pulmonary venous pressure) progresses further patient
becomes dyspneic in lying down position and feels better
in upright posture like sitting. This is called orthopnea. Often
the patient gives the history that he passes the whole night
reclining on something (several pillows, wall, etc). He may
prefer to sit near the edge of the cot with legs hanging down.
These postures reduce venous return and so reduce
pulmonary congestion, thereby reducing the severity of
dyspnea.
Chest Pain
Chest pain is a common cardiovascular complaint.
Excluding heart ailments chest pain can also be the
complaint in respiratory diseases (inflammation of the
parietal pleura), chest wall diseases, diseases in the upper
GI tract, diseases of the thoracic spine (root pain). Chest
pain due to heart conditions are mainly due to coronary
artery disease (CAD), pericarditis or dissecting aneurysm
of aorta.
The pain of CAD is known as angina pectoris which
has got certain specific features. It is primarily retrosternal
in site. The character of pain is not properly described by
most people. Various types of words are used by different
people. Oppressive feelings, sense of suffocation, sense of
heaviness, sense of squeezing and so on are the commonly
used words. Often an emotional involvement to the feeling
can be observed in the facial expression of the patient. In
fact the patient may start weeping while describing the pain
and he may say that he had a feeling of the end of life. While
describing he may make a fist and move over the sternum.
Moving the fist over the sternum suggests that the location
of pain is retrosternal and the fist suggests it is squeezing in
character. In stable angina patient will be forced to take rest,
but in acute myocardial infarction and unstable angina
patient may become restless in a vague attempt to get relief
(stable angina, unstable angina and myocardial infarction
are the spectrum of the clinical manifestations of CAD). The
pain of stable angina usually lasts for a few minutes. But in
unstable angina and myocardial infarction pain may persist
for several minutes. Anginal pain radiates to left shoulder,
left upper limb along the ulnar border, can radiate to the
right shoulder and arm, can radiate to the neck up to the
mandible, can radiate down to the epigastric area.
Conventionally it is told that anginal pain does not go above
the lower jaw and does not go below the umbilicus. Anginal
pain starts or aggravates on exertion or emotion and is
relieved by taking rest and nitrates. Pain of esophageal
spasm can be relieved by nitrate, but it has no relation to
exertion or emotion and is not necessarily relieved by rest.
Pain of myocardial infarction and unstable angina may start
at rest and may not be relieved by nitrates always.
Associated symptoms like profuse sweating, desire to
defecate, breathlessness, syncope suggest myocardial
infarction. CAD may not always present with typical pain
as described above. Some of the characters might be missing
in some cases. Pain might be completely missing in some
cases (painless myocardial infarction) or pain might be felt
only at the sites of radiation without being felt in the chest.
Patients may present as dyspnea, fatigability or palpitation.
These are known as angina equivalents.
Pain of pericarditis is more or less identical to angina in
relation to location and radiation, but it is more persistent.
Neither it is associated with other symptoms nor it is relieved
by rest or nitrates. It can be relieved by sitting up and leaning
forward, can be aggravated by deglutition.
Pain of dissecting aneurysm of aorta is severe enough to
mimic myocardial infarction. Sweating and other associated
symptoms of myocardial infarction may occur in these cases.
The difference is, this pain is tearing in character and it
radiates to the back between the two scapulae.
Swelling of the Body (edema)
Patients with heart disease may come with the complaint of
swelling of the body. This may be due to right-sided heart
failure, pericardial effusion, constrictive pericarditis,
restrictive cardiomyopathy, tricuspid valve diseases like
tricuspid stenosis and tricuspid regurgitation. In all these
conditions the primary factor giving rise to edema is the
increased hydrostatic pressure. So the swelling appears first
in the dependent parts; legs if the patient is ambulatory,
back of the thighs or over the sacrum if the patient is lying
down. If dyspnea preceded the swelling of the body it is
likely to be due to heart failure. Dyspnea is usually not a
complaint of pericardial disease, at least in the beginning.
Disproportionate accumulation of fluid in the peritoneum
(ascites) suggests a condition like tricuspid stenosis or
regurgitation, constrictive pericarditis and restrictive
cardiomyopathy. In all these conditions jugular veins are
engorged (also see gastrointestinal and urinary system).
Syncope
Syncope is transient loss of consciousness due to sudden
decrease in the cerebral blood flow. The commonest cause
of syncope is vaso-vagal syncope. Of the organic causes of
syncope cardiovascular cause comes first. Left ventricular
out flow tract (LVOT) obstruction like aortic stenosis and
hypertrophic obstructive cardiomyopathy (HOCM) are the
common causes of cardiac syncope. Presence of syncope in
these conditions suggests advanced stage of the disease.
Syncope can occur due to cardiac arrhythmias, particularly
ventricular tachyarrhythmia as seen in long QT syndrome
(Torsades de pointes) and due to marked bradycardia as
occurs in complete heart block and sick sinus syndrome.
A syncopal attack in the setting of bradycardia is known as
Stokes Adams attacks (SA attacks). The basic difference
between syncope and SA attacks is that syncope does not
occur in lying down posture (always occurs in upright
posture); where as SA attacks can occur in any posture. In
fact syncope in LVOT obstruction occurs on exertion (effort
syncope). LVOT obstruction as well as arrhythmia both can
cause syncope in cases of HOCM.
Other less common cardiac causes of syncope are acute
myocardial infarction, Tetralogy of Fallot (TOF), ball valve
thrombus in mitral stenosis. In acute myocardial infarction
syncope may be due to sudden fall in the blood pressure or
due to arrhythmia.
Palpitation
Palpitation is the feeling of own heart beat. Palpitation may
be due to tachycardia of any cause, due to arrhythmia,
usually at the time of change in rhythm (onset or the
termination of the arrhythmia) or due to large stroke volume
states like aortic regurgitation, mitral regurgitation,
ventricular septal defect, etc. If it is due to large stroke volume
it will be persistent (though it can be more marked in left
lateral position). If the palpitation is paroxysmal, it is likely
to be due to arrhythmia or tachycardia {as in paroxysmal
supraventricular tachycardia (PSVT) and pheochromo-
cytoma.
Hemoptysis
Hemoptysis is commonly due to respiratory diseases, but it
can be due to certain cardiovascular illnesses. Mitral
stenosis is by far the commonest cardiovascular cause.
Hemoptysis is seen in the early stage of mitral stenosis.
Frequency of hemoptysis decreases after the development
of pulmonary arterial hypertension. Other situations where
hemoptysis occurs are primary pulmonary hypertension
(PPH), Eisenmenger’s syndrome, TOF. A cardiovascular case
remaining bed ridden for a long time can develop pulmonary
embolism and hemoptysis.
Fever
Fever is an uncommon cardiovascular complaint. It can
occur in infective endocarditis, fresh attack of rheumatic
process, left atrial myxoma, acute pericarditis, pyoperi-
cardium. Low grade fever can occur in myocardial infarction
after a few days of the onset of infarction. Because cardiac
conditions are infrequent causes of fever, they are often
missed and they present as pyrexia of unknown origin
(PUO).
Neurological Deficit
Neurological deficit in cardiovascular illnesses are mostly
due to cerebral embolism. Type of neurological deficit
depends on the site of lodgment of the embolus. Mitral
stenosis, cardiomyopathy, mural thrombus in myocardial
infarction, vegetation embolism in infective endocarditis,
tumor cell embolism in left atrial myxoma, paradoxical
embolism in conditions with right to left shunt (TOF) are
the causes which predispose to embolism. In all these
conditions the neurological deficit is abrupt in onset. Focal
neurological deficit with convulsion can occur in children
with cyanotic congenital heart diseases due to development
of brain abscess.
Respiratory Infections
Repeated lower respiratory tract infection (bronchitis or
pneumonia) occurs in children with left to right shunt like
ventricular septal defect (VSD), atrial septal defect (ASD)
and patent ductus arteriosus (PDA). So called winter
bronchitis can occur several times in cases of mitral stenosis.
In all these conditions the respiratory infection may take
the form of bronchitis, bronchopneumonia or frank
pneumonia.
Cyanosis
Cyanosis is an uncommon mode of presentation of
cardiovascular illnesses. It is usually noticed by the
physicians when the patient is brought for some other
problem. Often it is associated with thickening of the finger
tips (clubbing). In cardiovascular illnesses there can be
central as well as peripheral cyanosis. Peripheral cyanosis
is associated with congestive heart failure. Central cyanosis
(where both warm parts as well as exposed parts are
affected) is seen in cases of cyanotic congenital heart
diseases like TOF, pulmonary atresia, tricuspid atresia,
double outlet right ventricle with pulmonary stenosis, and
others. In Eisenmenger’s syndrome (reversal of left to right
shunts like VSD, ASD, PDA) also there occurs cyanosis.
The differential cyanosis (toes are cyanosed, fingers are not)
is typically noticed in PDA with reversal. Presence of
clubbing with cyanosis invariably indicates central
cyanosis. Parents may be able to notice the cyanotic spells
in children with tetralogy of Fallot.
HISTORY OF PAST ILLNESS

In a patient with cardiovascular disease the following past
histories are likely to be significant.
History of Similar Illnesses

Some cardiological conditions can occur repeatedly. These
are- episodes of paroxysmal supraventricular tachycardia,
episodes of congestive cardiac failure, cyanotic spells of
TOF, cerebral embolism in cases with mitral stenosis, angina
of variable severity in cases with CAD, episodes of acute
rheumatic fever in cases with existing rheumatic heart
disease if the child is not receiving rheumatic prophylaxis
regularly.
History of Significant Illnesses

Acute Rheumatic Fever
If the child suffered from rheumatic fever in childhood, he
may suffer from various types of valvular heart diseases,
mitral stenosis being the commonest. Very often there is a
gap between the onset of rheumatic fever and development
of symptoms of rheumatic heart disease (RHD). Following
a single attack of rheumatic fever in childhood (5 to 15 years
of age) symptoms of RHD develops in third or fourth decade.
However, the patient may become symptomatic much earlier,
even in the very first decade.
Ask for migrating polyarthritis in childhood. It should
primarily affect the big joints. These inflamed joints are very
painful, so much so that the child may have to be lifted and
carried for toilet. Often the child misses school for a long
period. Also ask how many such episodes he has suffered,
whether he has received penicillin prophylaxis or not? It
should be kept in mind that a patient might be suffering
from RHD, yet he may not give history of rheumatic fever.
This is possible because if the major manifestations were
not arthritis and chorea, the child or the parents may not be
able know that the child had such an important illness in
childhood. Also remember that people often tell that there
was rheumatic fever, but unless it fits into the criteria
described above it should not be accepted easily. Any joint
problem in childhood is often considered as rheumatic fever.
This mistake is often done by the doctors. Rheumatic fever
is often over diagnosed.
Hypertension
Ask if at any time he has/had been detected to be
hypertensive. How to collect history of hypertension has
been described elsewhere. Hypertension can subsequently
cause or can be associated with left ventricular failure,
coronary artery disease, hypertensive hypertrophic
cardiomyopathy, dissecting aneurysm of aorta and co-
arctation of aorta.
Diabetes Mellitus
History of diabetes mellitus is important in CVS because, it
is a major risk factor for CAD. The association of diabetes
mellitus with CAD is so strong that it has been considered
as CAD equivalent. Diabetics may present atypically; as
painless myocardial infarction or with diastolic dysfunction.
Diabetics are also more prone to suffer from peripheral
vascular disease.
Syphilis
Aortic regurgitation, aneurysm of ascending aorta and
coronary ostial stenosis causing anginal pain are the
cardiovascular manifestations of syphilis. Cardiovascular
syphilis being a tertiary syphilis it takes fifteen to twenty
years for its development after the exposure. How to collect
history of syphilis has been described earlier.
Tuberculosis
Tuberculosis involving heart is relatively uncommon. The
cardiac problems of tuberculosis are pericarditis, pericardial
effusion and constrictive pericarditis. How collect history
of tuberculosis has been described too.
Chronic Respiratory Illnesses

There are several respiratory illnesses which can lead to
corpulmonale in later life. Most important among them is
chronic bronchitis and emphysema. Others are: interstitial
lung diseases, bilateral bronchiectasis, and gross deformity
of the chest wall and so on.
Maternal Illnesses and Therapy
In case of suspected congenital heart disease major illnesses
in the mother and drugs received during pregnancy have to
be collected. Maternal systemic lupus erythematosus (SLE),
Rubella are known to be associated with congenital heart
diseases. Drugs in pregnancy which are known to cause
foetal abnormality are anti-epileptic drugs (Diphen-
hydantoin and Carbamazepine), ACE inhibitors,
cyclosporine, lithium, retinoid and a few others.
FAMILY HISTORY
Hypertension, coronary artery disease, sudden death,
cardiomyopathy (particularly hypertrophic variety) can
occur in many members of the family. So enquire about these
illnesses in the family. Few other genetically transmitted
conditions which can be associated with cardiovascular
abnormalities are Marfan’s syndrome (AR, MR, and aortic
dilatation), Ehlers-Danlos’ syndrome (MR), Turner’s
syndrome (Coarctation of aorta, Bicuspid aortic valve),
Friedreich’s ataxia (cardiomyopathy and conduction
defects), Muscular dystrophy (cardiomyopathy), etc.
PERSONAL HISTORY
Occupation – Sedentary workers—CAD
Smoking – CAD and peripheral vascular disease
Alcohol – CAD and cardiomyopathy
IV drug addicts – Right-sided endocarditis
TREATMENT HISTORY
Treatment of cardiovascular diseases is often prolonged.
Hence enquire about the drugs the patient is already taking,
because doubling of prescription may lead to dangerous
complications (digoxin and anticoagulants). Drugs may
alter the physical signs, even the investigations. A few are
quoted here.
• If a patient is on digoxin the heart-rate may be slow in
spite of heart failure, the pulse deficit may be less (<10)
even if there is atrial fibrillation.
• ST segment changes may be due to drugs like digitalis
(inverted check mark), or quinidine like anti arrhythmic
drugs (long QT).
• If the patient has already received antibiotics, blood
culture may not show any growth of the organism in the
setting of infective endocarditis.
• If the patient has received glucocorticosteroids ESR may
become normal in spite of acute rheumatic carditis.
• Many other non cardiac drugs may have cardiac toxicity
or may have drug interaction with cardiac drugs. Hence
details of the drugs being taken for prolonged period,
drugs taken in recent past and the drugs being continued
should be taken into account before prescribing new
drugs for any cardiac ailment.
• Treatment with repeated blood transfusion is also
important as it is associated with hemochromatosis
leading to dilated cardiomyopathy.
MENSTRUAL HISTORY
Importance of menstrual history is same as in other
conditions. There are some cardiac conditions where
pregnancy should be avoided (already discussed).
Institutional delivery may be recommended for some
patients, surgical intervention may be needed for the cardiac
condition in spite of pregnancy. Radiological exposure
should be avoided as far as possible. One thing should be
remembered that in pregnancy there can be several
cardiovascular alterations without any true cardiac illness.
Also remember that the criteria for the diagnosis of
hypertension in pregnancy and in non-pregnant state are
different.
CHAPTER
13
History in
Neurological
Disorders
Before doing a lumbar puncture

ophthalmoscopy is a must.
It has been already discussed that three-fourth of the
diagnosis in a neurological case comes from history. If this
has not been achieved, history taking is considered to be
incomplete. Patient may not complain everything of his own,
he says what he feels important; but it is our duty to extract
as much information as possible by tactful questioning and
careful interpretation of the answers. The components of
the diagnosis in a neurological case are:
• Nature of the lesion
• Structures affected
• Site of the lesion
• Etiology (Cause).
These four parts should be obtained in that order. It
simplifies diagnosis. However, always it may not be possible
to follow the order. So alteration of the sequence does not
cause problem as long as total information are obtained.
NATURE OF THE LESION

Neurological disorders are classified into several groups
like; cerebrovascular, degenerative, demyelinating,
neoplastic (intracranial tumors), infective, deficiency
disorders, etc. These disorders behave more or less in a
predicted manner as regards their onset and course is
concerned. Nature of the lesion can be decided on the basis
of this clinical behavior. So in every case the exact mode of
onset and the clinical course should be known. However,
in acute neurological cases if the patient comes too early for
consultation it may not be possible to decide the course of
the disease. While deciding the course of the illness it is
History in Neurological Disorders 125
required to be sure whether the disease is progressing or
regressing. This is required because often people confuse.
To emphasize their illness they often tell that the neurological
deficit is worsening though it might be static or might be
improving a little. If you are following the case for some
time it will be easy to know the course of illness. But if it has
to be ascertained from the history some errors are possible.
Little improvement may not be appreciated by the patient or
the patient may not be happy with that much of
improvement for which he may not mention this as
improvement. For example, a patient who had grade 0
power and now has grade 2 power he has improved
scientifically. But the patient expected that he would be able
to walk (grade 4/5 power). So he might tell that there is no
improvement. Now let us see how much information we get
from the onset and course of the illness.
Gradual Onset and Progressive Course

Degenerative Disorders
Motor neuron disease, Parkinson’s disease, hredofamilial
ataxia, nutritional toxin mediated neuropathies
Space Occupying Lesions (SOL)

Here in addition to neurological symptoms there will be
features of raised intracranial pressure—headache, vomiting
and papilloedema. There can be convulsions also. All space
occupying lesions need not be tumors. Cysts, granulomas,
abscesses can also behave like intracranial space occupying
lesions.
That the neurological deficit is gradual in onset can be
known when the patient will not be able to tell the exact
time/day of onset of the illness. Often he says it is there
in the range of months or years.
Gradual Onset and Regressing Course

(tendency to improve)
Deficiency Disorders
With replacement of the deficiency factor there will be
improvement of the condition. Improvement may be
incomplete. (Vitamin deficiency neuropathy, subacute
combined degeneration of the cord).
Acute Onset and Worsening Course

Cerebrovascular Disease
Particularly cerebral hemorrhage (can happen to thrombosis
and embolism also). Infective disease: Tubercular
meningitis, Encephalitis.
Acute Onset and Regressing Course

Cerebro-vascular Disease
Thrombosis, embolism, hemorrhage all can improve.
Demyelinating Diseases
Infective Diseases
Pyogenic meningitis (tubercular meningitis and encephalitis
can improve also). The most important feature of an infective
disorder is it starts with fever. Fever might be a complaint in
intracerebral as well as in sub-arachnoid bleed, but it is
never the starting complaint in these conditions. In
meningitis the sequence of events is—fever, headache,
vomiting and altered sensorium. In case of sub-arachnoid
hemorrhage the sequence of events is, head ache, vomiting,
altered sensorium and fever.
Limitations of the Scheme to Decide the

Nature of the Lesion
This scheme works well in most of the situations, but there
are certain limitations to this.
• A CNS tumor may present as stroke due to bleeding into
the tumor.
• A space occupying lesion (neoplastic lesion, granuloma
or a cyst) may not have feature of raised intracranial
tension, particularly if the SOL is a small one and it is
situated in the supra tentorial region.
• The middle aged paraplegic form of multiple sclerosis
may start gradually and have a progressive course, even
if the nature of the lesion is demyelinating.
• Parkinson’s disease may improve in the initial part of
the course of the disease with treatment though it is
basically a degenerative condition.
• A case of SOL may improve temporarily with treatment
to reduce cerebral edema.
• Febrile illness of any kind can precipitate a paralytic
episode of multiple sclerosis mimicking an infective
nature of the illness.
• A group of disorders present in episodes. In between the
episodes the patient is completely normal. Epilepsies of
different kinds belong to this category.
• This protocol may not work well in spinal cord diseases
(details later on).
STRUCTURES INVOLVED
From history one can fairly know the structures involved.
The structures may be different parts of the brain like motor
system, sensory system, various cranial nerves, bladder and
bowel (autonomic), different parts of the brain (various lobes
of the brain, cerebellum, etc.). Let us see how we can know
these structures from history.
Frontal Lobe
Lesions in the frontal lobe can be suspected from the
following symptoms.
• Focal motor seizures
• Weakness, mostly as monoplegia
• Deterioration in mental function
• Change in social behaviour
• Impairment of vision (due to compression of the optic
nerve)
• Impairment of sense of smell (due to involvement of the
olfactory nerve)
• Speech defect, mostly in expression.
Parietal lobe
Some of the features of parietal lobe lesions are:
• There may be sensory Jacksonian type of fits.
• Sensory inattention on the opposite side of the body.
• Asteriognosis (inability to recognize known objects in
the affected hand in the darkness or with eyes closed).
• Speech defects mostly receptive if the dominant parietal
lobe is affected.
• Alexia and agraphia may be noticed in lesions of the
dominant angular gyrus lesion.
• Apraxia, various forms of agnosia (particularly finger
agnosia) and acalculia can also be seen.
• Lesion in the non-dominant angular gyrus can cause
disorder in body image, so that the patient develops a
tendency to neglect his affected one half of the body.
This can be noticed in the form dressing apraxia (he
may forget to put on the dress on the affected side, may
not be able to know right or left side of the dress).
• An abnormal type of movement disorder is noticed in
parietal lobe lesion. Both in resting as well as in action,
athetoid movements of the affected hand may be noticed
(pseudoathetosis).
• There may be visual field defects (quadrantic) due to
involvement of the optic radiation. This is rarely
complained by the patient, mostly revealed on
examination.
Unless meticulously enquired parietal lobe lesions may
be missed from history. Unless suspected from the history;
casual examination may also miss these defects as well.
Temporal Lobe
Lesions in the temporal lobe causes more ill defined
symptoms and if not carefully listened may be passed away
as hysterical or psychiatric condition. Some of the features
of temporal lobe lesions are:
• Various types of hallucinations (like auditory, gustatory
and olfactory) occur.
• There can occur uncinate fits (patient develops aura of
smell or taste followed by involuntary movements
involving lips, muscles of mastication, pharyngeal
muscles).
• There can be perverted memory. Patient may feel
unfamiliar things/events as familiar (déjà vu
phenomenon) or familiar things/events may be felt as
unfamiliar (jamais vu phenomenon).
• There can be visual field defects too (quadrantic).
• Emotional changes may be abrupt in onset. Panic attacks
may be noticed.
• Objects may appear smaller or larger, more distant or
near than the real.
• Patient may describe his past life events, may complain
of dreams of similar types coming repeatedly.
• There can be tinnitus, but hearing loss is uncommon.
• In lesion of the dominant temporal lobe there can be
Wernicke’s type of aphasia.
Occipital Lobe
Some of the features of parietal lobe lesions are:
• Visual aura may precede convulsions.
• There can be visual field defects which may affect the
way of living of the patient. The patient may hit the wall
on the affected side.
• There can be several types of visual agnosia, like object
agnosia, color agnosia, prosopagnosia (inability to
recognize face).
• Visual inattention is another specific feature of occipital
lobe lesion. However it may be difficult to detect occipital
lobe lesion from history only.
Excluding these four major territories in the brain other
sites like lesions in third ventricle or fourth ventricle have
their specific symptoms. Unless carefully enquired one is
likely to miss them. In most of the occasions the structure
affected can be known from the history. Truly these are better
known from history than from examination. Details of
symptoms of every site can be studied from the text books of
neurology.
Cerebellar Lesions
In cerebellar lesions the patient complains of difficulty in
walking/unsteadiness of gait. This may be misunderstood
as weakness of the limbs, so history should be collected
carefully to understand what exactly the patient means.
The patient may say that he is not able to put his feet in the
desired place. In the upper limb he may say that there is
tremulousness of the hands particularly in attempting to
hold something or picking up some object. He may not be
able to write clearly as he used to do it earlier, he may spill
the water while attempting to drink particularly when the
glass comes near the mouth. It may not be easy to conclude
all these features from the history only. Speech defect is
another obvious feature of cerebellar lesion. So try to mark
the type of speech while collecting history. In cerebellar
disorders speech becomes scanning type. Here the syllables
of a word get separated.
Often it is difficult to decide whether it is cerebellar
parenchymal lesion or lesion is in the cerebellar connection.
If the patient complains of truncal ataxia (patient will not
be able to sit or stand steadily), lesion is in the vermix of the
cerebellum; hence a primary cerebellar parenchymal lesion
rather than lesion in its connection. However, it will be
difficult in most of the situations even after careful
examination.
CRANIAL NERVES
First Cranial Nerve
Patient complains of loss of sense of smell or perverted sense
of smell. Unilateral lesion is rarely complained of, but it is
pathologically more significant than bilateral lesions. There
may be hysterical anosmia, where the patient not only
refuses that he is not able to smell anything but also refuses
to detect the irritating nature of ammonia (which is due to
stimulation of the fifth nerve). This type of hysterical anosmia
is found in cases of minor head injury where the victim
wants to get better compensation.
Second Cranial Nerve

Partial lesions in the optic nerve will cause blind spots in
the visual field, but this may not be always noticed by the
patient. More commonly patient complains of diminished
visual acuity (both to near and distant objects). With
progressive lesions of the optic nerve visual acuity
diminishes in a progressive manner:
• Inability to see small letters in a book or news paper
• Inability to see large letters
• Inability to count fingers
• Inability to appreciate hand movements
• Inability to appreciate light.
When a lesion of the optic nerve regresses it happens in
the reverse way. In the early stage of optic nerve lesion there
may be poor appreciation of color. One of the commonest
causes of sudden blindness is diseases of the optic nerve.
Transient monocular blindness (a shade passing across the
field of vision) may be a form of transient ischaemic attack
(TIA) involving the ophthalmic artery. Pain on movement
of the eye ball (in or behind the eye) suggests optic neuritis/
retro bulbar neuritis.
Third/ Fourth/ Sixth Cranial Nerve

These are the motor cranial nerves of the eye. The symptoms
of these cranial nerve lesions are diplopia and squint. The
patient may complain of two images of one object on
movement of the eye in a particular direction. If the lesion
lasts for a long time patient learns to neglect the false image
and may deny double vision. Squint is often detected by the
relatives. Squint can be utilized to know the presence of
ophthalmoplegia in unconscious persons too. One can ask
the relatives whether the patient was having squint from
early childhood (congenital) or he has developed it recently
(paralytic). There are several types of ophthalmoplegia; like
supranuclear, nuclear, infra nuclear and inter nuclear.
Squint and diplopia are features of nuclear and infranuclear
lesion. In supranuclear lesions there occurs conjugate
deviation of the eyes without diplopia. That is also
temporary. The other feature of third nerve involvement is
ptosis. In fact diplopia may be masked by ptosis due to
closure of the pupil. If the eye lid is lifted diplopia becomes
obvious. However ptosis may be due to primary muscle
disease (myasthenia gravis) or due to involvement of the
sympathetic fibers. If ptosis is associated with diplopia the
lesion is certainly in the third cranial nerve. In third nerve
lesion another symptom may be observed is impaired vision
particularly near vision. This is due to parasympathetic
nerve involvement causing dilatation of the pupil (loss of
accommodation).
Fifth Cranial Nerve

In fifth nerve lesion there is impaired sensation over half of
the face, so that the patient complains of numbness over the
affected area. If there is loss of pain and temperature
sensation also, he may complain that he is not able to
appreciate the temperature of water while washing his face;
may also say that he is not able to feel the hotness/coldness
of the food or drink in the affected cheek. Due to involvement
of the motor component (involvement of the muscles of
mastication) he might say that there is deviation of the chin
to one side (to the side of the paralysis) on attempt to protrude
the mandible. There may be difficulty in chewing too.
Seventh Nerve
From history one can know whether it is/was upper or
lower motor neurone type of facial palsy. In lower motor
neurone lesion eye remains open even during sleep (due to
paralysis of the orbicularis oculi) and the angle of the mouth
is deviated to the opposite side (due to paralysis of the
orbicularis oris). In upper motor neurone lesion eyes are not
affected though angle of mouth is affected. In some situations
eyes are affected without affection of the mouth. This is
possible in partial lesions involving the terminal fibers of
the facial nerve (i.e. leprosy). Remember that these facial
asymmetries are often first noticed by the relatives than the
patient himself, particularly the condition of the eye. The
patient notices only when he sees his face in a mirror.
However, the patient may complain of drooling of saliva or
leakage of water from the angle of the mouth or overflow of
lachrymal fluid from the affected eye.
Eighth Nerve
Unilateral 8th nerve lesion may not be easily revealed from
history. Persistent tinnitus in a particular ear may suggest
lesion in the vestibulocochlear nerve of that side. However
intelligent people can complain of diminished hearing in
one ear. In such situations invariably the lesion is in the
infranuclear segment of the nerve, because unilateral
supranuclear lesion does not affect hearing. If the vestibular
component is affected also there will be vertigo, but severe
vertigo is not a feature of 8th nerve lesion, rather it is due to
involvement of the vestibular nucleus or its central
connections. Tinnitus is another symptom of eighth nerve
lesion. Tinnitus is rare in cortical lesions. If at all it is in the
form of a noise, often taking the form an auditory
hallucination. Tinnitus occurs in lesions of the acoustic
apparatus (cochlear/retrocochlear components of the 8th
nerve).
Ninth, Tenth Cranial Nerves

Truly lesions of these nerves are better revealed from history
than from examination. The symptoms are dysphagia,
dysphonia and dysarthria. Other evidence may be nasal
regurgitation of food/water and nasal intonation of voice,
induction of cough while taking food or drinks. Patient may
have difficulty in swallowing his own saliva resulting in
its accumulation in the throat. He may carry a spittoon/pot
to collect his saliva. Relatives may complain that the patient
is having excessive snoring and mouth breathing during
sleep. Unilateral upper motor neurone lesion of these nerves
does not cause any problem.
Eleventh Cranial Nerve

Isolated eleventh cranial nerve lesion is uncommon. It is
involved along with the 9th and 10th cranial nerves; hence
the symptoms are as described in 9th and 10th nerve lesion.
However, due to bilateral paralysis of the sternomastoid
and the trapezius patient may not be able to keep the head
straight. In sternomastoid paralysis (as in myotonic
dystrophy) head tends to fall forward and in trapezius
paralysis (motor neurone disease, poliomyelitis and
myasthenia gravis) head tends to fall backward. There will
be dropping of the shoulder on that side and he may
complain of difficulty in lifting of the arm above the head.
Twelfth Nerve
There will be dysarthria (difficulty in uttering t and d) and
deviation of the tongue to one side (to the paralyzed side).
He may have difficulty in chewing and in swallowing food.
In upper motor neurone lesions the tongue may appear small
and stiff. Unilateral upper motor neurone lesion does not
affect articulation.
MOTOR SYSTEM
For normal movement intact bones and joints, intact muscles
for the particular movement, the intact neural part
controlling the muscular contraction are required. Though
the extrapyramidal system and the cerebellum are also
required for movement, but generally the motor system is
meant by the upper motor neurone (UMN) and the lower
motor neurone (LMN). The nerve cells in the motor cortex
and its fibers (the corticospinal tract/pyramidal tract)
constitute the upper motor neurone. The anterior horn cells,
the anterior root and the motor peripheral nerve form the
lower motor neurone. From history one can know whether
it is UMN or LMN lesion. In both there will be weakness.
When weakness is associated with atrophy (in patient’s
language it is thinning) of the limb/part it is suggestive of
LMN lesion. However, it takes few weeks for atrophy to
develop. Hence, it may not be possible to differentiate an
acute LMN lesion from acute UMN lesion from history only.
The limb in LMN lesion is limp, so that he is not able to
maintain any posture. A wider range of passive movement
will be possible around the affected joints. In UMN lesion
the limb feels stiff so that there is limited range of passive
movement and more resistance to it. There may be abnormal
posture of the limb. Remember that in an acute UMN lesion
(state of spinal shock) all these features might be missing. In
lower motor neurone lesion the other thing which the patient
or the relatives may complain is flickering involuntary
movements (fasciculation) in the affected muscles.
Paraplegia, monoplegia, quadriplegia can be both due to
UMN and LMN lesion. However, hemiplegia is mostly due
to UMN lesion.
Peripheral nerve is a part of the lower motor neurone. So
weakness due to involvement of the peripheral nerve can
also occur. As most of the peripheral nerves are mixed nerves
lesions of peripheral nerves causes weakness and sensory
loss. However, there are few neuropathies which affect
predominantly motor fibers (lead neuropathy). In such
conditions weakness and thinning (atrophy) starts from
the peripheral parts and progresses to proximal parts of the
same muscle or more proximal muscles of the limb are
involved. In conditions like peroneal muscular atrophy,
atrophy of the muscles progresses horizontally; initially in
the lower limbs, later in the upper limbs also. Often the
patient himself notices this and says that the disease is eating
him from below upwards.
Another type of motor deficit occurs due to primary
diseases of the muscles like myopathy and muscular
dystrophy. Myopathy often affects a group of muscles (Limb
girdle type, Facioscapulo-humeral type, proximal type, etc.)
and invariably it is symmetrical. No fasciculation is
complained by these patients. There will be thinning
(atrophy) of the affected muscles.
From history one can know which groups of muscles
are affected. If the proximal muscles of the lower limbs are
affected patient will have difficulty in getting up from sitting
posture. He requires support if he tries to get up. Often he
uses his own body to get up (climbing his own body). In the
upper limbs the patient will have difficulty in doing work
above head like combing hairs or putting something on the
shelves over head. If the distal muscles, say small muscles
of the hands are affected he will have problem in doing
finer work like writing, painting, buttoning and unbuttoning
the dresses etc. With involvement of the intrinsic muscles of
the foot, the patient will face difficulty in walking on wet/
slippery/muddy surface.
The other part of the motor system is the extra-pyramidal
system. Here there will be changes in the tone (both
hypertonia and hypotonia possible). The patient will
complain of stiffness or limpness of the limbs. There may be
various types of involuntary movements; the commonest
being tremor. The peculiarity of tremor due to extra-
pyramidal disorder is it occurs in the resting state involving
the distal parts like fingers (tremor decreases on putting the
limb into action). What ever may be described in words, it
will be difficult to give full description of all the involuntary
movements. Hence students should see all varieties of
involuntary movements and get acquainted with them. In
addition to the involuntary movements, gait and postural
abnormalities are the other problems of extra pyramidal
disorders. Hence all these points have to be enquired if extra-
pyramidal disorder is suspected.
SENSORY SYSTEM
Symptoms related to the sensory system are more vague
and nonspecific. However patient may complain of some
positive symptoms like root pain or negative symptoms like
numbness. It is very difficult to know the types of sensory
abnormality from history only. Even examination may not
yield satisfactory result in every case. Remember that
sensory examination should be done when the patient is
fully cooperative and relaxed; at times it may take several
sittings. Depending on the type of structure affected
there will be different types of sensory findings. Some of
them are:
Sensory Loss in Patches
May be hypopigmented leprosy.
Mono-neuropathic Type
Sensory loss will be according to the distribution of the
concerned nerve. For example, in ulnar nerve lesion there
will be sensory loss in the medial side of the hand, in median
nerve lesion there will be loss of sensation on the lateral
three and half fingers of the hand, in lesions of the common
peroneal nerve loss of sensation will be on the lateral aspect
of the leg and on the dorsum of the foot. So one should have
knowledge about sensory distribution of all major
peripheral nerves.
Poly-neuropathic Type
Here sensation will be impaired first in the distal parts.
Longer the peripheral nerve earlier it will be affected. So
often the complaint starts in the lower limb (in the foot) and
then in the upper limb (in the hands). So it is named as
gloves and stocking type of sensory loss. All modalities are
almost equally affected though some modalities like
vibration may be lost little earlier.
Root Type
There may be root pain. This is a burning, constricting or
electric shock like pain which increases on coughing,
sneezing and movements of the spine. Root pain can get
relieved in a particular posture; change of posture can bring
on pain. Pain radiates along the course of the peripheral
nerve to which the concerned nerve root supplies. Sensory
loss will be along the distribution of the corresponding root.
So one should have knowledge about dermatomal
arrangement of the body. Again all modalities of sensation
will be equally affected.
Tract Type
There are two main sensory tracts. The posterior column
and the spinothalamic tract. The posterior column carries
touch, vibration, position sense and joint sense. Lesion in
this tract will produce sensory ataxia. The patient will have
difficulty in walking in darkness or may have unsteadiness
on closure of the eye. He may also tell that he does not feel
anything below a particular level. He might say that he
does not feel whether he has cloth in the affected part or not.
If the sensory deficit is gross he may say that his body has
been divided below the particular level. To know whether
the limbs are in correct position or not, he has to voluntarily
move the limbs over a wider range. Similar thing may happen
in lesions involving the upper limbs, so that the patient
repeatedly moves the fingers to know their position (piano
playing movements). The sensory level is more clearly
described by the patient when it is over the trunk, but when
it is on the limbs patient may not be able to tell an exact level
(it is to be found out by examination). In lesions affecting
the spinothalamic tract patient will not be able to feel pain
or temperature sensation so that he might develop painless
injuries/ulcers, may develop blisters due to hot compression
or burns due to cigarette buds. Dissociated sensory loss is
also a tract type sensory loss, where pain and temperature
sensations are lost whereas posterior column types of
sensations are preserved. This is seen in syringomyelia,
intramedullary tumors, lateral medullary syndrome etc.
Hemi Sensory Loss
Here sensation is lost over one half of the whole body (often
all modalities equally), i.e. body as well as face. The lesion
is in the region of internal capsule.
Hemi Sensory Loss With Thalamic Over Reaction

In lesions of the thalamus in addition to the loss of sensation
on half of the body, there is exaggerated appreciation of
pain sensation on the affected side.
Cortical Type of Sensory Loss

Here primary sensations are intact. From history it will be
difficult to know this type of sensory impairment. But
asteriognosis may help. Very rarely the patient may say
that he is not able to identify the object by holding on the
affected hand, but on transferring the object to the other
hand he is able to detect it easily (all of course either in
darkness or with eyes closed).
Asked meticulously and interpreted carefully lot of
information can be obtained from history about the sensory
system.
SITE OF LESION
After knowing the structures affected one should know
where they are affected. Just knowing the structures affected
will not serve the purpose. For example, the pyramidal tract
(cortico spinal tract) extends from cerebrum to the lowest
part of the spinal cord (lower border of L1 vertebra). Similarly
just knowing that the 7th cranial nerve is affected is not
enough. We have to know where it is affected. Because, it
starts from the pons and passing through the cerebello-
pontine angle, the middle ear and the parotid gland ramifies
into all the muscles of facial expression. We have to know
where these structures are affected in their long course. This
applies to almost all neurological structures. Involvement
at a particular site is likely to affect the surrounding
structures. To put a lesion exactly at a site one has to know
the neuro-anatomy thoroughly.
The major structures and their relative placement should
be remembered. The anatomy of the spinal cord and brain
stem at different levels should be clearly known. The
structures and function of the cerebral cortex, the basal
ganglia, and cerebellum are also to be remembered. The
cerebral arterial circulation and the venous circulations,
the CSF (cerebrospinal fluid) pathway, intracranial and
extracranial courses of the cranial nerves, the root value
and the course of the peripheral nerves all are important.
Always attempt should be made to put the lesion at one
place in stead of putting multiple lesions. Let us discuss
some examples.
Example 1: A common structure affected in several
neurological conditions is involvement of the corticospinal
tract, presenting with motor weakness. The localization of
the lesion will be as follows:
• Monoplegia with convulsion—cerebral cortex
• Monoplegia without convulsion—corona radiata
• Hemiplegia with same side UMN facial palsy—internal
capsule
• Cross hemiplegia—brain stem lesion (Depending on the
site, the corresponding motor cranial nerve will be
affected. This cranial nerve paralysis will be LMN type
and it will be on the opposite side of the limb weakness
(same side of the lesion). Hence it is called cross
hemiplegia.
• Hemiplegia without any cranial nerve palsy—spinal
hemiplegia.
Example 2: If a patient has got seventh and eighth nerve
lesion and cerebellar signs on the same side, the probable
site of lesion is cerebellopontine angle (CP Angle).
Example 3: If a patient has got unilateral/bilateral 3rd and/
or 4th nerve (even 6th nerve) with unilateral/bilateral
pyramidal sign, the probable site of lesion is inter-
peduncular fossa (as seen in tubercular meningitis).
Example 4: If a patient has got unilateral 3rd, 4th and 6th
nerve paralysis with numbness (sensory impairment) in
the upper part of the same side face, the probable site of
lesion is near the superior orbital fissure.
Example 5: If a patient has got proptosis and congestion of
the eye and weakness of 3rd and 4th cranial nerve,
numbness in the face (5th nerve) on the same side, the
probable site of lesion is near the cavernous sinus.
Example 6: If a case comes with paraplegia with thinning
(atrophy) of the legs probably the lesion is below L1 vertebra
(Cauda equina lesion); similarly if there is paraplegia
without any complain in the upper limb and without
atrophy (thinning), the lesion is somewhere between T2 and
L1. If there is quadriplegia/quadriparesis and it is a cord
lesion (say there is bladder involvement) the site of lesion
will be in the cervical cord. Quadriplegia with lower cranial
nerve involvement/cerebellar symptoms suggests high
cervical cord compression.
Once the nature of the lesion, structures affected and the
site of lesion are identified it is easy to reach at an aetiological
diagnosis.
APPROACH TO A CASE WITH SPINAL CORD DISEASE

In a case with spinal cord disease the approach is little bit
different. Let us first discuss how to suspect that it could be
a primary spinal cord problem. The following points will
help.
• If the complaints are solely confined to limbs without
any symptoms of cranial nerve involvement or changes
in the higher function (speech, consciousness,
convulsion, memory, etc.).
• If bladder and bowel are affected.
• If there is history suggestive of root pain/tract pain.
• If the patient is able to appreciate a definite sensory level.
• If there is bony deformity of the spine and the complaints
(what ever he has got) correlate with the deformity.
However, it has to be kept in mind that there can be both
spinal cord as well as intracranial lesions.
In a case with spinal cord problem it is required to
differentiate whether it is a compressive or a non-
compressive myelopathy. This is important because
compressive lesions are basically curable conditions if
operated in time. Hence the decision has to be made quickly.
Features of Compressive Myelopathy

1. Most of the compressive myelopathies are gradual in
onset and progressive in course except traumatic
paraplegia, prolapse of the intervertebral disc, spinal
epidural abscess/hematoma, collapse of a vertebra
(which may be due to Pott’s spine, secondaries or
multiple myeloma). In these later conditions there will
be acute cord compression.
2. Presence of root pain. It is a type of pain which is
appreciated along the distribution of the affected root; it
is a burning, constricting or electric shock like in
character; increases on coughing, sneezing and
movement of the spine.
3. Presence of vertebral deformity and/or tenderness.
4. Sequential involvement of limbs or tracts. For example,
one upper limb is affected first, then lower limb of the
same side, then lower limb of the opposite side and
opposite side upper limb is affected last ( seen in intra-
dural extramedullary compression). Similarly, it may
start with motor weakness; later on develops sensory
impairment and then bladder is affected.
5. Asymmetry of the lesion goes more in favor of
compressive lesion. To start with non compressive
lesions may be asymmetrical also, but soon becomes
symmetrical. Poliomyelitis and monomelic variety of
motor neurone disease are asymmetrical even if they are
non compressive lesions.
6. If the patient is able to tell a sensory level it is more likely
to be a compressive lesion. However, acute non-
compressive lesion like transverse myelitis may have a
level too.
In summary, it can be told that none of these features is
diagnostic of compressive myelopathy. So no conclusion
should be drawn from any single point. All the points must
be judiciously considered to reach at a conclusion. After
deciding that it is a compressive lesion a probable level can
be ascertained from the history also (see Example 6, under
structures affected). However, exact level can be known after
examinations only.
PAST HISTORY IN A NEUROLOGICAL CASE

As in any other case past history should include similar
illnesses and significant illnesses.
Similar Illnesses
Neurological disorders which are likely to occur again and
again (similar) are epilepsy, transient ischaemic attacks,
multiple sclerosis, periodic paralysis, sub-arachnoid
haemorrhage. Of course stroke can occur repeatedly. Very
rarely the neurological deficits of ADEM (Acute
Disseminated Encephalomyelitis) can recur.
Significant Illnesses
Significant past history depends on the type of neurological
disorder. Let us discuss some examples.
• History of hypertension is significant in a case of
cerebrovascular accident (CVA).
• History of TIA is significant in a case of CVA.
• History of rheumatic heart disease, recent myocardial
infarction (mural thrombus) is important in a case of
embolic stroke.
• In a suspected case of brain abscess history of CSOM
(chronic suppurative otitis media), cyanotic congenital
heart disease may be significant.
• History of syphilis is significant in several types of
neurological problems.
• History of vaccination/viral infection in recent past is
significant in ADEM. Acute post-infective polyneuro-
pathy can also occur following viral infection.
• History of head injury may be important in a case of
epilepsy.
• History of tuberculosis is significant in a suspected case
of compressive myelopathy, tubercular meningitis, and
multiple cranial nerve palsy.
• History of recent child birth is important in a case with
loss of consciousness with or without convulsion (could
be puerperal cortical venous sinus thrombosis).
• Acute cerebellitis may occur in cases of chicken pox and
typhoid fever.
• History of diabetes mellitus may be important in
evaluating cases of metabolic encephalopathy and
stroke.
There are many more which one can know with progress
in overall knowledge in neurology.
FAMILY HISTORY IN A NEUROLOGICAL CASE

The following conditions may occur in several members of
a family. These conditions may be:
a. Genetically transmitted conditions:
• Muscular dystrophies
• Heredo-familial ataxias
• Different types of HSMN (Hereditary sensory motor
polyneuropathy).
• Huntington’s chorea
• Remember that all the features may not manifest
equally in all affected members of the family.
b. Familial clustering disorders: These are mostly nutritional
toxin mediated diseases like lathyrism, nutritional
neuromyelopathies.
Even if there is no family history of similar illness is
present, history of consanguineous marriage in the
family should be obtained. Autosomal recessive
disorders can get manifested by this.
PERSONAL HISTORY
• In a strictly vegetarian (vegan) vitamin B12 deficiency
leading to sub-acute combined degeneration of the cord
is possible.
• A person working in lead industry may suffer from lead
neuropathy.
• Sewerage workers may suffer from leptospiral
meningitis.
• Recent change in bladder habit (hesitancy, urgency,
incontinence etc) is highly significant in a neurological
case. Bladder involvement may be the early sign of
intramedullary lesion and is the late feature of extradural
cord compression. Bladder affection is often (not always)
a feature of completeness of a spinal cord lesion. In the
setting of compressive lesion bladder involvement
warrants early surgical intervention. Unilateral
corticospinal tract lesion does not affect the bladder (if
at all transient). In conditions of dementia and in frontal
lobe lesion there may be decline in social behavior
so that the patient may pass urine where he is not
supposed to do under normal situation. Similarly, in a
recovering spinal cord disease bladder may be the last
to recover.
TREATMENT HISTORY
Treatment history is important under certain situations like:
• Treatment status of hypertension and diabetes mellitus
is required in evaluating an unconscious patient.
• Discontinuation of antiepileptic drugs may precipitate
status epilepticus.
• Consumption of certain drugs can cause polyneuro-
pathy, optic neuritis and auditory neuropathy.
• If it is a partially treated case one has to remember that
the physical signs, even investigations may get modified
(partially treated pyogenic meningitis, tubercular
meningitis, etc.).
• In recurring neurological problem like epilepsy one
should know the response to previous treatment so that
one can plan the future management.
CHAPTER
14
History in
Respiratory
Disorders
For catheterizing the bladder never be

miser in using the xylocaine jelly.
The components of diagnosis in a respiratory case are:
1. Pathological (like consolidation/fibrosis/collapse, etc.).
2. Anatomical (like upper lobe/lower lobe/pleural, etc.).
3. Etiological (like bacterial/fungal/neoplastic, etc.).
If possible respiratory functional status can be added to
these components of diagnosis; means whether there is any
compromise in the primary functions of the respiratory
system, i.e. oxygen and carbon dioxide exchange or not.
History gives maximum information in a respiratory
case, more than in a neurological case. If 75% of the diagnosis
in a neurological case comes from history, possibly 90% of
the diagnosis comes from history in a respiratory case.
History is more important in a respiratory case because very
often the physical findings are confusing and misleading.
Next to history if anything contributes more to diagnosis in
a respiratory case is the X-ray chest. So students should be
well versed in interpreting chest X-ray. A case with
respiratory disease may present with the following
complaints singly or in combinations. These complaints
are:
• Cough (with/without sputum production)
• Dyspnea
• Haemoptysis
• Fever
• Chest pain.
COUGH
Cough is the single most important complaint of respiratory
diseases. Rarely is it noticed in diseases elsewhere. It is a
protective reflex. It tries to keep the respiratory tract clean.
Cough may be associated with sputum production or it may
History in Respiratory Disorders 153
be dry. Dry cough suggests disease is in the upper respiratory
tract or in the pleura. However, there can be dry cough in
early parenchymal disease as in congestive stage of
pneumonia and in interstitial lung diseases. It may be dry
in early stage of bronchial tree disease like early stage of
bronchogenic carcinoma and smoker’s cough. Cough may
be apparently dry in children and women as they often
swallow the sputum. Cough with sputum production
suggests lesion in the lower respiratory tract (below the vocal
cords); it may be in the bronchial tree or in the lung
parenchyma (part of the lung distal to the terminal
bronchiole). The type of sputum produced helps in the
diagnosis. Always try to see sputum yourself. The different
types of sputum which can be encountered are:
a. Purulent: Here the sputum is thick and pus like. Such
sputum is seen in lung abscess, bronchiectasis and
amoebic liver abscess communicating to the lungs. In
the latter condition the sputum is anchovy sauce type
and the patient may be able to tell that there is flavour of
liver when it is expectorated.
b. Mucopurulent: Sputum is a mixture of mucus and pus;
seen in acute exacerbation of chronic bronchitis, also
can be seen in tuberculosis.
c. Mucoid: Sputum is like mucus; typically seen chronic
simple bronchitis.
d. Rusty sputum: Sputum is uniformly mixed with small
amount of RBCs as happens in the stage of red
hepatization of pneumonia.
e. Black sputum: seen in coal workers, can be seen following
exposure to smoky environment.
f. Frothy sputum: Seen when there is lot of water/watery
secretion in the lungs. This occurs in cases of drowning
and organophosphorus poisoning. Pink frothy sputum
is characteristic of pulmonary edema.
g. Red currant jelly sputum: seen in Klebsiellar pneumonia
(jelly like sputum mixed with blood).
In addition to these types of sputum produced some
other characters of cough and sputum may help in the
diagnosis.
• Profuse sputum is seen in lung abscess, bronchiectasis,
pulmonary edema (always ask the patient to collect the
24 hours sputum).
• Foul smelling sputum is seen in lung abscess,
bronchiectasis. In these conditions sputum may not be
foul smelling always as it is dependent on the presence
of anerobic organisms.
• Timing of cough also helps in diagnosis. In chronic
bronchitis, pulmonary tuberculosis and bronchiectasis
cough is more marked in the morning. In chronic
bronchitis cough is more marked in the winter season.
Patient coughs vigorously but brings out only little
amount of sputum (tenacious sputum). Patients of
chronic pharyngitis and nasal obstruction often cough
more at night.
• Cough and sputum production is often more marked in
a particular body position in lung abscess and
bronchiectasis. At times cough is increased in lying down
posture and relieved in upright posture as in left
ventricular failure. This may also be seen in mediastinal
tumor and diaphragmatic hernia. In the former cough
may be associated with dyspnea. (There was a case of
large amebic liver abscess who was having persistent
cough in lying down posture; so much so that he was
not able to sleep; for which he had to sit the whole night.
This cough was relieved after aspiration of pus from the
liver. This was because there had been a small leak of
the abscess to the lung and the leakage was only in lying
down posture; and no leakage in upright posture. After
aspiration the liver tissue grew and sealed the leak).
• Smoker’s cough typically increases after smoking.
• Cough which only comes on deglutition is seen in
patients with lower cranial nerve palsy and tracheo-
esophageal fistula.
• Abrupt onset of a cough (may be associated with
dyspnea) in a child may due to foreign body aspiration.
• Character of cough can also help in diagnosis. At times
it is possible to give the diagnosis only by listening to
the cough. Bovine cough indicates paralysis of the vocal
cords. Here the explosive nature of the cough is lost.
Following a prolonged bout of cough a child takes a
long noisy inspiration (whoop) is diagnostic of whooping
cough. In pleurisy attempt to take deep inspiration or to
cough causes pain so that the patient becomes afraid of
coughing forcefully; but due to the underlying disease
he has to cough. Here he suppresses the violent nature
of the cough. This type of cough is often called a
suppressed cough, which is typically seen in pneumonia
with pleurisy. Barking cough is a loud cough without
expectoration seen in hysterical conditions. Often it starts
abruptly. Brassy cough (metallic tinge to the cough) may
be due to compression of the major airway from outside.
Paroxysmal cough may be a variant of bronchial
asthma.
DYSPNEA
Dyspnea primarily occurs in diseases of the respiratory or
cardiovascular system.
Dyspnea due to respiratory diseases may be of long
duration or may be of short duration.
Dyspnea of Long Duration

The causes of long duration dyspnea are bronchial asthma,
chronic bronchitis, emphysema and interstitial lung
diseases. History can reveal the cause in most of these cases.
In these conditions dyspnea will be of several months or
several years in duration:
• If it is episodic in nature and associated with wheezing—
Bronchial asthma. There may be several months to
several years gap between the episodes.
• If it is persistent without wheezing—interstitial lung
disease. Examination of these cases does not reveal much
physical findings. So, often these cases are considered
as malingering, at least in the initial part of their illness.
• Persistent with wheezing—perennial bronchial asthma.
• Dyspnea associated with cough and sputum
production—chronic bronchitis.
In pure emphysema there is no sputum production. But
chronic bronchitis and emphysema coexist very often. In
chronic bronchitis cough and sputum production occur
earlier than dyspnea (at times years before). Dyspnea in
chronic bronchitis may mimic the episodic nature of
bronchial asthma due to acute exacerbation of the disease.
The points to remember are—the outstanding feature of
chronic bronchitis is sputum production and the
outstanding feature of bronchial asthma is wheezing.
Dyspnea of Short Duration

There are some situations where dyspnea is of few hours/
days in duration. Such causes are:
• Pulmonary collapse
• Pneumothorax
• Pulmonary infarction
• Diaphragmatic/Intercostal muscle paralysis
• Pneumonia involving more than one lobe
• Massive pleural effusion
• Major airway obstruction even without causing collapse.
In most of these conditions dyspnea is maximum at the
beginning except in tension pneumothorax (not in closed
or open pneumothorax), massive pleural effusion and major
airway obstruction. As the function of the lost lung is taken
up by the healthy lung, severity of dyspnea tends to
decrease. This takes a few days. Therefore, the severity of
dyspnea decreases with the progress of time. In massive
pleural effusion and in tension pneumothorax as long as
fluid or air goes on accumulating in the pleural space
dyspnea also goes on increasing. In cases of major airway
obstruction if the obstruction is increasing in nature (growth)
dyspnea may increase, if it is regressing in nature (Mucus
plug) dyspnea may decrease. However, the most important
feature of major airway obstruction is stridor (noisy
inspiration). Similarly, if the intercostal muscle paralysis
progresses (ascending paralysis) dyspnea will increase. This
becomes more obvious if the diaphragm is affected. If the
diaphragmatic paralysis is due to compression of the
phrenic nerve, dyspnea will decrease with the progress of
time, because the function of the diaphragm is taken up by
the intercostal muscles.
There are some situations where dyspnea may be of
neither long (years) nor short duration (days); it may be in
terms of months. This may be seen in initial stage of
bronchial asthma, or initial stages of other causes of long
standing dyspnea. However, one cause that typically falls
in this category is pulmonary eosinophilia.
HEMOPTYSIS
True haemoptysis is coughing out of blood from the lower
respiratory tract. However common people often tell this as
vomiting of blood. They say so because they feel whatever
comes out of mouth is coming from the stomach, hence it is
vomiting. Obviously, they do not have knowledge about the
anatomy. Hence always try to differentiate hemoptysis from
hematemesis (discussed elsewhere). It is also required to
differentiate from spurious hemoptysis. Here the blood
comes from the oral cavity or the upper respiratory tract.
This can be easily known if the oral cavity and the nose and
throat are sincerely examined.
The common causes of hemoptysis are:
Respiratory Causes
• Tuberculosis
• Bronchogenic carcinoma
• Bronchiectasis
• Lung abscess
• Chronic bronchitis
• Pulmonary infarction
• Bronchial adenoma
• Pulmonary AV malformation
• Fungal infection of the lungs.
Non-respiratory Causes
Cardiological conditions
• Mitral stenosis
• Primary pulmonary hypertension
• Eisenmenger’s syndrome
• Tetralogy of Fallot, etc.
Hematological Conditions
• Thrombocytopenia of different causes
• Rarely in coagulation disorders.
Renal Causes
Goodpasteure’s syndrome: In any case of hemoptysis one
should try to find out the associated symptoms. These
associated symptoms often help to find out the cause of
hemoptysis. For example,
1. Cough, fever, weight loss with haemoptysis—
pulmonary tuberculosis(Remember that in pulmo-
nary tuberculosis irrespective of the clinical findings
X-ray is invariably abnormal but X-ray may be normal
in endobronchial tuberculosis. These cases often
present with haemoptysis. Also remember that
haemoptysis can occur in healed tuberculosis.
2. Long history of profuse and purulent sputum, now
having hemoptysis—bronchiectasis.
3. Short history of profuse purulent sputum, now having
hemoptysis—lung abscess.
4. Frank hemoptysis with weight loss (may be a
smoker)—could be bronchogenic carcinoma.
5. Repeated small amount haemoptysis without
deterioration in health (usually young female)—
Bronchial adenoma.
6. Repeated massive haemoptysis without deterioration
in health—pulmonary AV malformation.
7. Sudden onset of dyspnea followed by hemoptysis
(often in a bed ridden patient)—pulmonary infarction.
8. Dyspnea on exertion with hemoptysis—mitral
stenosis.
9. Hemoptysis in a case with cyanotic heart disease—
TOF, Eisenmenger’s syndrome.
10. Long-standing cough with expectoration and
hemoptysis (blood streaked sputum)—chronic
bronchitis.
11. Pneumonic onset (high fever, cough, chest pain)
followed by red current jelly sputum—Klebsiellar
pneumonia.
12. If there is bleeding from other sites with hemoptysis—
bleeding/clotting disorder.
If a patient has got a long-standing underlying lung
disease and he develops hemoptysis off and on, one should
not simply think that the cause of hemoptysis is due to the
underlying lung disease. Bronchogenic carcinoma may be
missed in early stage in the setting of chronic bronchitis
(both occur in smokers), Fungal infection (for example,
Aspergilosis) may be missed in a cases of tuberculosis. In
fact it has been advised that every episode of hemoptysis
should be evaluated as a fresh case.
FEVER
Fever as in most of the cases usually indicates infection in
the respiratory system.
High fever occurs in inflammation of the lung
parenchyma (pneumonia). High fever can also occur in
empyema thoracis and lung abscess. A single shaking chill
with high fever associated with cough (with/without
pleuritic chest pain, with/without sputum) suggests
pneumonia. This is the typical pneumonic onset. Often the
patient remembers the exact time of onset of fever; as precisely
as in hours.
Low grade fever can occur in upper respiratory infection
and infection in the bronchial tree (bronchitis).
There may not be fever in both these conditions. Irregular
fever occurs in pulmonary tuberculosis. In tuberculosis fever
can persist for months. In fact one of the commonest causes
of pyrexia of unknown origin in a tropical country like India
is tuberculosis. Fever may be more marked in the evening.
Fever can occur in pulmonary infarction, but it occurs late;
never it is the starting complaint.
CHEST PAIN
Chest pain is mainly due to respiratory, cardiac cause or
chest wall cause. But it can also be due to diseases of upper
abdominal structures, due to oesophagus or it could be
referred pain.
Respiratory
The only pain sensitive structure in the respiratory system
is the parietal pleura. So pain due to diseases of the
respiratory system has to involve the parietal pleura. This
type of pain is called pleuritic chest pain.
The feature of pleuritic chest pain is it increases on deep
inspiration and on coughing. It is a localized pain (often
the patient points to the site of pain with a finger). If pleurisy
proceeds to the development of pleuraleffusion pain
subsides. Similarly, in a case of pleural effusion after
aspiration of pleural fluid pain may recur due to both pleural
surfaces coming on contact with each other and rubbing.
Cardiac
Angina, pericarditis and dissecting aneurysm of aorta are
the cardiac causes of chest pain (details already discussed).
Chest Wall
The causes are trauma, fracture of a rib, metastatic deposits
on the rib(secondary/multiple myeloma), infective
conditions of the skin, costochondritis, etc. The hallmark of
a chest wall pain is it is associated with tenderness. However
there are some intra-thoracic/intra-abdominal conditions
which can be associated with tenderness are empyema and
amoebic liver abscess respectively. In all cases of chest pain
in the lower part intra-abdominal conditions should be
excluded and in all cases of upper abdominal pain intra-
thoracic conditions should be excluded.
Referred
Pain is referred from nerve roots (Herpes zoster, vertebral
diseases and extramedullary tumors).
PAST HISTORY
As usual in past history similar illnesses and significant
illnesses should be collected.
Similar Illnesses
Respiratory illnesses which can occur repeatedly are
• Bronchial asthma
• Acute exacerbations of chronic bronchitis
• Acute infections in bronchiectasis
• Fibrocystic disease
• Pneumothorax (at times).
Repeated respiratory infections can occur in the following
conditions.
• Mitral stenosis
• Left to right shunt (ASD, VSD, and PDA)
• Splenectomized individuals
• AIDS
• Congenital agammaglobulinemia
• Multiple myeloma
• Diabetes mellitus, etc.
The respiratory infection in these conditions may be in
the form of bronchitis or pneumonia.
There are some underlying lung conditions which can
predispose to repeated attacks of pneumonia in the same
segments, as seen in bronchiectasis, bronchostenosis and
bronchial growth.
Significant Illness
• AIDS, diabetes mellitus, prolonged glucocorticoid
therapy predispose the individual to tuberculosis.
• Silicosis and chronic bronchitis can predispose to
tuberculosis.
• History of loss of consciousness, epileptic fits, alcohol
intoxication, and surgery under general anesthesia are
important in suspected cases of lung abscess.
• In suspected cases of bronchiectasis history of measles
or whooping cough in childhood may be significant.
FAMILY HISTORY
Genetically transmitted conditions of the respiratory system
are few.
Alfa 1 anti-trypsin deficiency causing emphysema is
one such disease. Bronchial asthma can occur in many
members of the family though the exact mode of transmission
is uncertain. Being air borne in nature tuberculosis can affect
many members of the family due to repeated exposure.
PERSONAL HISTORY
Significant personal history in a respiratory case are:
• Smoking: Chronic bronchitis, bronchogenic carcinoma
• Alcohol: Aspiration pneumonia, tuberculosis
• Extramarital sexual contact: AIDS and related respiratory
illnesses
• Housing condition: May help in ascertaining a
precipitating factor of bronchial asthma.
CHAPTER
15
History in
Gastrointestinal
Disorders
If in the same patient there is anemia

and hypoproteinemia, mostly the
cause is in the GI Tract.
Very little information is obtained from examination of the
patients with diseases of the gastro intestinal system.
Temporal profile of the illness is extremely important to
reach at a diagnosis in these cases. Hence history, which
reveals the temporal profile, is of outmost importance in
gastro intestinal disorders. The common complaints with
which cases of gastrointestinal (GI) disorders present are:
• Abdominal pain
• Abdominal swelling
• Vomiting
• Dysphagia
• Diarrhea and constipation
• Jaundice
• Hematemesis (vomiting of blood)
• Melena/hematochezia
• Bleeding per anum
• Weight loss.
ABDOMINAL PAIN
Abdominal pain is a common complaint in clinical practice.
There can be acute and chronic painful conditions. Acute
painful abdominal conditions are more common and it needs
sound power of clinical judgment for coming to a
conclusion. These conditions not only give pain to the patient
but also improper approach and treatment may lead to fatal
outcome or may lead to unnecessary surgery. In acute
abdominal conditions history gives maximum information
and often can clinch the diagnosis. Time spent to get an
accurate history is never wasted. Rather there are instances
where valuable time has been wasted for investigations and
the patients have died due to delay in surgery (at times on
History in Gastrointestinal Disorders 167
the investigation table). In less clear cut cases history should
be taken and examinations should be done repeatedly while
the patient is on conservative treatment or being
investigated. If investigations are done without reaching at
a provisional diagnosis from history and examinations; the
later may completely confuse the clinical set-up. For
example, if a case comes with a clinical picture suggestive
of acute appendicitis and an abdominal ultrasound is done
early (when there may not be any evidence of appendicitis
sonographically) and if it shows stones in the gallbladder,
the case may be treated as acute cholecystitis (though the
stones may be silent and are just accidentally detected).
Acute Abdominal Pain

While evaluating a case with abdominal pain few things
must be kept in mind. These are:
• Abdominal pain may not be due to abdominal
conditions. It is the rule that in all cases of upper
abdominal pain exclude the possibility of an intra-
thoracic condition like myocardial infarction or
diaphragmatic pleurisy. Pain of nerve root origin can
also be felt on the abdomen.
• Abdominal pain does not mean disorders of the GI tract
or the related structures like liver, gall bladder, etc; may
be due to structures of the genito-urinary system.
• Possibility of occlusion of the intra-abdominal blood
vessels
• Menstrual history in a female case should not be missed.
• All acute abdominal conditions need not be surgical.
Few conditions like acute intermittent porphyria, lead
poisoning, Henoch Schönlein purpura, acute metabolic
conditions like diabetic ketoacidosis and uremia, gastric
crisis of tabes dorsalis, sickle cell crisis, etc. can present
as acute abdomen. These are non-surgical conditions.
While collecting history the things to be clarified are:
• Types of pain
• Site of pain and its radiation
• Bladder and bowel
• Associated symptoms.
Types of Pain
Colicky Pain: Obstruction to hollow viscus with limited
distensibility causes colicky type of abdominal pain. This
pain is of abrupt onset, quickly reaches a peak and abruptly
subsides. During the peak of the pain the patient becomes
restless, may roll over, may press something (like pillow) on
the abdomen, and may tie something (like a piece of cloth)
on the abdomen. Classically there are two types of colicky
pain, i.e. intestinal colic and ureteric colic. Small intestinal
colic is referred to periumbilical region and large intestinal
colic is referred to hypogastric area. Though intestinal colic
is commonly due to intestinal obstruction but it can be due
to exaggerated peristaltic movement also. This is the
mechanism of colicky pain in lead poisoning and in acute
intermittent porphyria. In ureteric colic pain starts from loin
radiates to groin and medial side of upper part of thigh and
to the genitals (scrotum/labia majora).
There are few other situations where even if there is
obstruction to hollow viscera typical colicky pain is not
produced. These are obstruction of ureter at pelvi ureteric
junction, biliary tract obstruction and obstruction of urinary
bladder at bladder neck. Obstruction at pelvi ureteric
junction causes persistent pain (so called renal colic) at renal
angle. Hence renal colic is not a true colic. Biliary tract
obstruction particularly obstruction to common bile duct of
acute onset can cause colicky type of pain (biliary colic), but
commonly it causes dull aching pain in right hypochon-
drium which may be referred to inferior angle of right
scapula. Similarly, obstruction of the cystic duct causes
constant type of pain in the right hypochondrium. Chronic
obstruction to the biliary tract may not be painful at all (as
in obstruction due to carcinoma head of pancreas).
Obstruction to bladder neck causes retention of urine
causing fullness of the bladder. If sensory system is intact it
causes a constant aching pain in the suprapubic region. In
a patient with impaired level of consciousness this may be
the cause of persistent restlessness. Though intestinal
obstruction causes pain; gastric outlet obstruction does not
cause pain, rather vomiting becomes the prominent
complaint.
Persistent abdominal pain: This may be two types—localized
or diffuse.
i. Localized: Persistent localized pain is due to inflammation
of the viscera, as in hepatitis, cholecystitis, pancreatitis,
appendicitis, etc. The pain will be felt over the
corresponding dermatome when the surrounding
parietal peritoneum is not affected and over the organ
involved if the surrounding parietal peritoneum is
affected. In the latter situation it will be associated with
tenderness and rigidity. Though the rigidity can not be
complained by the patient, tenderness can be marked by
the patient. However, both these features are to be
confirmed by examination. For example, in acute
appendicitis initial pain felt in the umbilical area is the
referred pain to its dermatome and pain shifts to the
right iliac fossa when the surrounding parietal
peritoneum gets involved. This is also the explanation
of the tenderness in the McBurney’s point.
In hepatitis, pain is due to stretching of its capsule.
This occurs if the stretching is over a short period as
noticed in acute hepatitis and congestive heart failure.
Gradual stretching does not cause pain as in fatty liver
or carcinoma of the liver. A peculiar character of pain is
felt in amoebic liver abscess. Here pain is exaggerated
on jerky movement so that the patient is afraid of walking
briskly and often he walks by putting his hand over the
liver (supporting the liver).
Pain of acute pyelonephritis is a deep seated
abdominal pain, but the patient primarily complains of
pain in the renal angle (angle between the 12th rib and
erector spinae muscle).
Pain of acute pancreatitis is felt in the epigastric
and umbilical region and is referred to back which is
exacerbated on lying supine and partly relieved on sitting
up with trunk bending forward. Pain of acute
cholecystitis is felt in the epigastric area or over right
hypochondrium, may be referred to right shoulder.
ii. Diffuse: Persistent and diffuse abdominal pain is due to
acute peritonitis. This may be due to several reasons.
Some common causes are:
i. Perforation of hollow organs like
• Peptic ulcer
• Enteric perforation
• Inflamed appendix
• Gangrenous segment of strangulated intestine
• Caecum in large gut obstruction and so on.
ii. Rapture of other viscera like
• Amebic liver abscess communicating to
peritoneum
• Gallbladder causing biliary peritonitis
• Spleen leaking blood into the peritoneum
• Ectopic pregnancy leaking blood into the
peritoneum and so on.
If the content discharged into the peritoneum is infected
(amoebic liver abscess, colonic content) inflammation will
be more severe than when the content is non-infective.
Leakage of blood and bile will cause less severe
inflammation. Leakage of gastric content (highly acidic) and
pancreatic enzymes as in acute pancreatitis will cause severe
inflammation. Sudden leakage will cause more severe
inflammation than gradual leakage.
Once there is peritonitis there will be diffuse tenderness
and rigidity of the anterior abdominal wall. The pain and
tenderness will increase on any sort of movement. Hence
the patient prefers to lie down quietly. Such patients when
asked to sit will do so at their own comfort; avoiding any
type of help. Sneezing and coughing also increases pain.
It is to be remembered that earlier two types of pain
(colicky and localized persistent) can end up in diffuse
persistent abdominal pain with the development of
peritonitis.
Referred pain: The other type of pain which is felt on the
abdomen is referred pain. Here none of the abdominal organs
is involved. The common causes are intra-thoracic
conditions like ischaemic myocardial pain (unstable
angina/myocardial infarction) and diaphragmatic pleurisy.
Irritation of the nerve roots (T-7 to L-1) due to diseases of the
spine causes pain on the anterior abdominal wall along the
distribution of the corresponding nerve root. Neuralgic pain
along the distribution of one or few dermatome can be felt in
Herpes Zoster. This may be really difficult to know in the
early pre eruptive stage of the condition.
Pain on the abdominal wall: Diseases affecting the abdominal
wall can also cause abdominal pain. It may be a hematoma
(on rectus sheath) or a parietal abscess. Here the pain is
localized and it may be associated with localized swelling
and tenderness. Throbbing character suggests abscess.
Vascular pain: Vascular pain may be due to occlusion of the
mesenteric artery or due to rupture of the abdominal aortic
aneurysm. Though these conditions are mostly catastrophic
in onset, but at times the onset may be gradual. Patient may
complain of mild abdominal pain for a few days before the
sudden severe pain associated with circulatory collapse. In
mesenteric artery occlusion there can be bloody diarrhea.
Pain is usually diffuse type but initially it can be colicky
type also. In rupture of the abdominal aortic aneurysm pain
will be referred to the sacral area and perineum. A type of
pain occurs in atherosclerotic narrowing of the mesenteric
artery called abdominal angina. Here pain starts fifteen to
thirty minutes after intake of food and persists for several
hours in the postprandial state.
Though one can predict the diagnosis from the features
of the pain only, but the associated symptoms help the
maximum to reach at a diagnosis.
Fever: High fever with chill occurs in perinephric abscess
and acute pyelonephritis. Fever with chill also occurs in
cholangitis. Fever not necessarily high also occurs in acute
cholecystitis, acute appendicitis and inflammatory
conditions of other intra-abdominal organs. Fever for some
days (two to three weeks) followed by diffuse abdominal
pain suggests enteric perforation.
Jaundice: Jaundice occurs in hepatitis and cholangitis.
Intermittent fever, abdominal pain and jaundice (Charcot’s
biliary triad) suggests cholangitis. In hepatitis by the time
jaundice appears fever subsides.
Hematuria: Ureteric colic associated with haematuria
suggests stone in the urinary tract. Sometimes passage of
clots can have similar pictures (clot colic).
Circulatory collapse: Abdominal pain followed by circulatory
collapse suggests the possibility of splenic rupture, rupture
of ectopic pregnancy, mesenteric artery occlusion, rupture
of abdominal aortic aneurysm. If the pain is in the upper
abdomen exclude myocardial infarction.
Amenorrhea, abdominal pain, shock: In early pregnancy
ruptures of ectopic pregnancy and in late pregnancy
abruptio placentae should be thought of. In both conditions,
there may or may not be vaginal bleeding. Of course vaginal
bleeding further helps in the diagnosis. But the combination
of amenorrhea, abdominal pain and vaginal bleeding
commonly suggests abortion.
Strangury: Suggests stone is near the vesico-ureteric junction,
can be a feature of pelvic peritonitis. It is painful straining
for passing urine, often with passage of little amount of
urine.
Vomiting: Vomiting frequently accompanies many acute
abdominal conditions. So vomiting may not help always. If
there is projectile vomiting it suggests intestinal obstruction.
Vomiting is often persistent in intestinal obstruction and in
acute pancreatitis; however, in acute appendicitis vomiting
occurs only for a few occasions at the onset. In the setting of
intestinal obstruction, vomiting occurs early if the site of
obstruction is in the proximal part, late if the obstruction is
in the ileum or in the large gut. The sequence of events in
small gut obstruction is pain-vomiting-abdominal
distension; in large gut obstruction it is pain-distension-
vomiting.
Bowel: In all cases of acute abdomen enquire about the bowel
habit. Marked constipation for some days may later on
present with features of intestinal obstruction. If the history
is taken meticulously it will be revealed that constipation
occurred much before the onset abdominal pain. In these
settings manual removal or an enema will solve the problem
and can avert an unnecessary surgery (I have seen a few
such cases). Absolute constipation (no passage of flatus or
faeces) occurs in both dynamic as well as adynamic
obstruction (paralytic ileus). However there can be few
motions at the onset, till the distal segment is evacuated in
dynamic intestinal obstruction. Red currant jelly stool (stool
containing only mucus and blood) may be seen in cases of
intussusception. Bloody diarrhea in the setting of acute
abdomen suggests mesenteric artery occlusion.
I have seen a female case with colicky abdominal pain
with swelling of the abdomen being misdiagnosed as
intestinal obstruction, though she was in labour pain. I have
also seen cases of rupture ectopic pregnancy being treated
otherwise and the condition being detected on the operation
table. These happened because of missing the menstrual
history. So, in every female case with abdominal pain
menstrual history is mandatory and always a pregnancy
related condition should be excluded, which may be
abortion, labour( premature/term), rupture of ectopic
pregnancy or abruptio placentae.
Chronic Abdominal Pain

Though there are several causes of acute abdomen, chronic
abdominal pain occurs in limited conditions. These are some
of the examples.
• Acid peptic disease
• Chronic pancreatitis
• Chronic cholecystitis
• Diverticulitis
• Irritable bowel syndrome (IBS)
• Subacute intestinal obstruction.
In cases of acute abdomen as discussed history gives
maximum information, but examination of the patient
reveals some valuable findings. However, in chronic painful
conditions of abdomen examination of the patient does not
show many findings. Hence one has to depend more on the
history to reach at a conclusion. It has to be remembered
that the so called pain in these conditions may not be truly
painful; it may be a sense of discomfort. The following
aspects are to be clarified to reach at a diagnosis:
Site of pain:
• Epigastric or slightly to the right of epigastric area—
duodenal ulcer
• Epigastric or slightly to the left of epigastric area—
gastric ulcer
• Right hypochondrium nearer to the costal margin—
chronic cholecystitis
• Diffuse/central abdominal pain—subacute intestinal
obstruction (May be tubercular)
• Hypogastric region/left iliac fossa—diverticulitis/
IBS
Relationship to food:
• Food relieves pain—duodenal ulcer
• Food brings on pain—gastric ulcer
• Intolerance to fatty food—chronic cholecystitis/
chronic pancreatitis
Timing of pain: Pain occurring in late hours of night or early
morning- duodenal ulcer. Pain which is often diffuse starting
fifteen to thirty minutes after intake of food and lasts for
several hours suggests abdominal angina. (Chronic
mesenteric ischemia)
Vomiting: Induced vomiting (by putting finger into the
throat)—gastric ulcer.
Voluminous projectile vomiting suggests gastric outlet
obstruction. However in conditions of gastric outlet
obstruction pain is rarely present possibly with the
exception of pylorospasm due to an active duodenal ulcer.
In other situations there can be a sense of discomfort (often
a sense of fullness). Intermittent vomiting is possible in sub-
acute intestinal obstruction.
Appetite: True anorexia occurs in carcinoma of stomach, but
it rarely causes pain unless it infiltrates into the posterior
abdominal wall. However dyspepsia to fatty food occurs in
gall bladder diseases. Dyspepsia to protein rich food occurs
in carcinoma stomach. In gastric ulcer appetite is preserved,
but patient may be afraid of taking food as food increases
pain. In mesenteric ischemia large meals causes more pain
for which patient prefers to take small food at a time.
Fever: Abdominal pain with fever is seen in cholangitis,
may be seen in abdominal tuberculosis.
Weight loss: Chronic abdominal pain associated with weight
loss may be seen in malignant conditions, abdominal
tuberculosis, due to exocrine pancreatic insufficiency in
patients with chronic pancreatitis, at times in chronic
mesenteric ischemia.
Bowel: Alternate constipation with diarrhea occurs in
intestinal tuberculosis and in irritable bowel syndrome. In
abdominal tuberculosis there will be weight loss, in IBS this
does not occur.
ABDOMINAL SWELLING
If a patient comes with the complaint of abdominal swelling,
enquire whether it is localized or generalized.
Localized Abdominal Swelling

A localized swelling (often complained as a mass) later on
can behave like a generalized swelling. Hence ask from
which site it started. Depending on the site of origin of the
swelling one can predict the organ from which it might
have arisen. For example:
• From epigastric area—stomach, left lobe of liver
• From right hypochondrium—right lobe of the liver, gall
bladder
• From left hypochondrium—spleen
• From lumbar region—kidney, colon
• From right iliac fossa—cecum, appendix, ovary
• Left iliac fossa—sigmoid colon, ovary
• Hypogastric region—bladder, uterus, ileum.
Lymph nodes can form a swelling almost anywhere.
Any of these organs if hugely enlarged can occupy almost
the whole abdomen and can mimic a generalized abdominal
swelling.
Generalized Abdominal Swelling

In case of truly generalized abdominal swelling (abdominal
protuberance) the patient will not be able to tell from which
site it started. The causes of such abdominal protuberance
are fat, flatus, faeces, fluid and in female fetus.
Fat rarely causes problem. It is ordinarily not complained
of. If at all, it will be over a prolonged period and it will be
part of the whole body obesity.
Flatus causes abdominal protuberance (distension) in
the setting of intestinal obstruction (both dynamic and
adynamic), acute dilatation of stomach and toxic mega colon.
In all these situations the total clinical picture will be so
obvious that it will rarely be a diagnostic problem.
Feces causing abdominal swelling are similarly rare.
The causes are congenital megacolon, a problem of early
childhood. Acquired mega colon can be seen in adult.
It may be due to myxoedema and Chagas’ disease. The
outstanding accompanying complaint will be marked and
prolonged constipation.
Fetus causing abdominal swelling is often obvious.
History of amenorrhea in the child bearing age group is the
most important accompanying complaint. Other signs of
pregnancy may also be there. Though it is invariably
obvious, but at times it can put the doctor in a delicate
situation. Pregnancy in an unmarried girl or in a widow
may not be accepted by the guardians easily, particularly in
our society. I have seen parents charging the doctor under
such situations. So one should be tactful in dealing with
such situations; better it will be to ask for documentary
evidence like a pregnancy test of urine or an abdominal
ultrasound.
The commonest cause of generalized abdominal
swelling is fluid (ascites). One should have a rational
approach to cases of ascites. Ask the following points.
• Whether it is associated with swelling of feet or face? If
so where the swelling started? If swelling started in the
feet before it appeared in the abdomen, the likely
underlying cause is increased hydrostatic pressure, as
seen in cardiac causes like right-sided heart failure,
pericardial effusion, constrictive pericarditis, restrictive
cardiomyopathy. In constrictive pericarditis, restrictive
cardiomyopathy and in presence of tricuspid
regurgitation and stenosis, ascites will be disproportio-
nately more than the leg edema. In fact in constrictive
pericarditis and restrictive cardiomyopathy, patient may
complain of swelling of the abdomen before swelling of
the feet. Swelling of the face precedes swelling of the
abdomen in patients with nephrotic syndrome. If the
patient categorically says that swelling of the abdomen
started first and the swelling remained confined to the
abdomen for a considerable time the probable cause is
in the abdomen itself, like tubercular peritonitis,
malignant ascites or acute peritonitis. In cirrhosis of liver
and in subacute hepatic failure (SAHF) though swelling
of the abdomen develops earlier than swelling of the
legs, but sooner or later leg edema appears. In hepatic
veno-occlusive disease there can be isolated ascites too.
• Whether it has occurred over a short duration (days) or
over a long duration (months). Ascites develops over a
short period in acute peritonitis; there can be acute
increase in the size of ascites over existing long-standing
ascites as seen in spontaneous bacterial peritonitis.
Rapid accumulation of ascites can occur in malignant
ascites and acute Budd-Chiari’s syndrome.
• Other associated symptoms should be asked for.
Jaundice will suggest subacute hepatic failure and
decompensated cirrhosis. GI bleeding can also occur in
both these two conditions. Ascites with features of altered
sensorium (encephalopathy) will suggest SAHF or
Cirrhosis of liver. Fever and abdominal pain occurs in
acute peritonitis or spontaneous bacterial peritonitis. It
can be a feature of abdominal tuberculosis also. In most
of the conditions of acute peritonitis the total clinical
picture will give the clue to diagnosis. Dyspnea antedates
the development ascites in cases of congestive cardiac
failure. Huge ascites alone can cause dyspnea where it
occurs late in the total clinical course. Marked weight
loss with ascites may be of malignant or tubercular in
origin. It also may be a part of malabsorption state (ascites
due to hypoproteinemia).
VOMITING
Vomiting is a common symptom of many illnesses. It always
does not mean that the disease is in the GI system. In
evaluating a case presenting with vomiting the following
points should be looked for.
Duration
Vomiting might be there for a long time (for months) or for a
short time (days/hours). At times it might be there for a long
time but only happens in episodes.
Short Duration Vomiting

Acute abdomen: Almost all types of acute abdominal
conditions are associated with vomiting. In all these
conditions abdominal pain is the outstanding complaint.
Vomiting in all these situations acts as a measure to protect
the GI system as a whole. It tries to keep the GI tract free from
food which is the most important stimulus for action of all
the organs of GI system; may be it liver, pancreas,
gallbladder, small intestine or large intestine. By emptying
the GI tract it helps in giving rest to these organs.
Acute gastritis: May be due to drugs or food poisoning. So in
all cases of vomiting of acute onset, ask if the patient has
taken any drugs recently. There are many oral drugs which
cause vomiting. Vomiting due to drugs are often more
frequently seen in children and women. The drug is more
likely to cause vomiting in the initial part of the drug
consumption; in the later part of the course the same drug
may not cause vomiting. Even some drugs administered
parenterally can also cause vomiting like morphine,
aminophylline or quinine. These latter drugs can cause
vomiting by stimulating the CTZ/vomiting center (so
without causing gastritis). Unpalatable food or
contaminated food can cause vomiting. It may be associated
with diarrhea (enteritis). Other persons who have taken the
same food might be having similar complaints. Intake of
poisons of various kinds also causes vomiting.
Increased intracranial pressure: Meningitis, encephalitis, head
injury, cerebro vascular accident, etc. can raise the
intracranial pressure and can cause vomiting. So associated
complaints like convulsion, fever, headache and altered
sensorium should be enquired.
Acute labyrinthitis: It will be associated with vertigo.
• Acute myocardial infarction particularly inferior wall-
associated symptoms like chest pain, dyspnea, etc. may
be there.
• As a part of vasovagal syncope
• Acute non GI infections can also cause vomiting
particularly in children.
Long Duration Vomiting

Vomiting may persist for several months. This may be again
episodic or persistent.
i. Episodic vomiting: Episodic vomiting is encountered
in the following conditions.
• Some forms of epilepsy (autonomic)
• Migraine (may or may not be associated with
headache)
• Meniere’s disease (will be associated with vertigo
and impaired hearing)
• Motion sickness—occurs on movement in vehicles
or merry go round games.
ii. Persistent vomiting:
• Gastric outlet obstruction—voluminous, projectile,
vomitus containing food of previous days.
• Uremia—may be associated with oliguria, swelling
of the body, etc.
• Endocrinopathies—hypo and hyperparathyroid
states, Addison’s disease.
• Brain tumors—associated with localizing features
and other features of raised intra cranial tension.
• Gastric motility disorders—diabetic gastroparesis
• Morning sickness—in early pregnancy
• Psychogenic vomiting—there will not be true act
of vomiting and usually does not lead to weight
loss even if the complaint lasts for a long time.
Timing
• Morning—morning sickness of early pregnancy, water
brush of APD, alcoholics
• Late afternoon—pyloric stenosis.
Content of the Vomitus
Always try to see the content of the vomitus yourself.
• Faeculent material—gastrocolic fistula, late stage of
large gut obstruction
• Food of previous day—gastric outlet obstruction.
Special Features
• Induced vomiting is seen in gastric ulcer. Here the patient
feels pain or abdominal discomfort following intake of
food. To get relief he puts his finger in the throat to induce
vomiting. As the patient vomits out freshly taken food,
after some time he will lose weight.
• Projectile vomiting is seen in cases with raised intracranial
pressure, pyloric stenosis, dynamic intestinal
obstruction, particularly if the obstruction is in the
proximal intestine. The vomitus is ejected with great
force. Often the content is also large in amount.
• Motion induced: Vomiting is induced by motion, either
in a vehicle or in a merry-go round games. This is known
as motion sickness. Usually, it is seen in younger persons
and females.
Associated Symptoms
Out of all features the associated features helps maximum
to reach at a diagnosis. For instance,
Associated symptoms Likely problem
Anorexia, nausea, edema Uremia
Anorexia, vomiting, Carcinoma stomach
Weight loss (prepyloric)
Diarrhea Infective (food poisoning)
Abdominal pain and Intestinal obstruction
distention
Fever, headache, Meningitis, encephalitis
altered sensorium
Fever, jaundice Hepatitis, cholangitis
Sense of something moving Pyloric stenosis
in the abdomen
Early pregnancy Morning sickness
Vertigo Labyrinthitis, Meniere’s
disease, acute cerebellar
disease
Headache, convulsion, Intracranial space
focal neurological deficit occupying lesion
Chest pain, Dyspnea, Acute myocardial infarction
Sweating
Episodic headache Migraine
And so on.
JAUNDICE
If a patient comes primarily with the complaint of jaundice,
it is imperative to decide whether it is hemolytic,
hepatocellular or obstructive jaundice. This can be fairly
confidently decided from the history.
Hemolytic
Often history dates back to childhood. It will be associated
with growth retardation, bony changes, failure to thrive due
to anemia. In hemolytic conditions jaundice is usually mild,
urine is not colored. At times hemolytic jaundice can lead to
obstructive jaundice (due to pigmentary gallstones), when
it will behave like obstructive jaundice.
Hepatocellular
Common causes of hepatocellular jaundice are drug
induced, viral and alcoholic. So enquire about intake of any
hepatotoxic drug, alcoholism or prodromal symptoms of
hepatitis (fever, anorexia, arthralgia, nausea, vomiting and
malaise). Here the eyes will be yellow as well as the urine
will be yellow.
Obstructive
In obstructive jaundice urine is colored but stool is clay like.
There may be pruritus and bleeding diathesis. It has to be
remembered that cholestatic phase of hepatitis may have
all these features.
If the patient concludes himself from the yellow color of
urine that he is suffering from jaundice it may not be always
true. Exclude history of intake of drugs which can cause
yellow/orange colored urine; like B complex vitamins,
rifampicin, pyridium (Phenazopyridine). Excess intake of
carrot can also cause yellowish urine. Less water intake
can lead to passage of high colored urine also.
Duration of jaundice can also help in the diagnosis of
the probable cause of jaundice. Jaundice from childhood
(may be of variable severity) suggests hemolytic jaundice or
congenital hyperbilirubinemia. In chronic hepatitis jaundice
may last for more than six months.
Pain in abdomen with jaundice is seen in hepatitis,
obstruction to common bile duct due to gall stone and
cholangitis. Painless progressive jaundice (obstructive
nature) is likely to be due to carcinoma head of pancreas.
Jaundice associated with mass in epigastric/right
hypochondrium may be due to carcinoma gallbladder,
secondaries in the liver, distended gallbladder as in
carcinoma head of pancreas. Jaundice with ascites will
suggest subacute hepatic failure, decompensated cirrhosis,
hepatic and peritoneal metastasis. Recurrent jaundice, fever,
abdominal pain occurs in cholangitis. In addition to this,
waxing and waning type of jaundice can be noticed in
chronic hepatitis, hemolytic jaundice, periampullary
carcinoma, obstruction of common bile duct due to a
papilloma with peduncle.
GASTROINTESTINAL BLEEDING
Bleeding from the GI tract can manifest as hematemesis,
melena, hematochezia and bleeding per anum.
Hematemesis and Melena

Hematemesis means vomiting of blood. Bleeding from
stomach, duodenum and oesophagus (upper GI tract) will
present like this. If the bleeding is small in amount it may
not cause blood vomiting, rather it will present as melena.
Melena is commonly understood as black stool. But simple
black stool may not be melena. In true melena stool will be
black, tarry and will have offensive smell, with a tendency
to stick to the lavatory pan. Black stool may be due to intake
of iron, bismuth salts and charcoal. Whenever doubt, try to
see the stool yourself. When hematemesis and melena both
are present there is little doubt.
In relation to hematemesis few things need clarification.
They are:
1. Whether it is hematemesis or hemoptysis?
2. What is the amount?
3. What is the probable cause?
Whether it is hematemesis or hemoptysis?

Bleeding from oral cavity should also be excluded in all
cases; particularly if the amount of blood loss is small. If
you get a chance to see the act of hematemesis/hemoptysis
it will be decisive. These are some of the differentiating points.
• In hematemesis there will be act of vomiting and nausea,
whereas in hemoptysis there will be act of coughing.
• The blood in hemoptysis is frank red containing clot; in
case of hematemesis blood will be coffee ground in colour
(there may be small pieces of clots). Of course massive
hematemesis can be frank red and can contain clots.
• Vomitus may contain food material; there will be sputum
or saliva (spurious hemoptysis) in case of hemoptysis.
• Hematemesis will be associated with melena;
hemoptysis usually does not. But if sufficient amount of
blood is swallowed hemoptysis can also cause melena.
What is the Amount?

In relation to hematemesis often people exaggerate the
amount of blood loss (discussed earlier). So in stead of
frankly accepting the statements of the patient/attendants
objectively assess the amount of blood loss. From history it
will not be easy to assess. However, if the patient has got
excessive thirst, sweating, decreased urination, air hunger
(restlessness) due to cerebral hypoxia the blood loss is
expected to be massive.
What is the Probable Cause?

From the history alone one can guess the probable cause of
upper GI bleeding.
• Persistent vomiting and retching followed by
hematemesis—Mallory-Weiss tear.
• Known case of cirrhosis with massive hematemesis—
rupture esophageal varices.
• Marked anorexia/new onset dyspepsia in a person
above 40 years of age with weight loss with melena/
hematemesis—carcinoma stomach.
• Hematemesis followed by altered sensorium—variceal
bleeding precipitating hepatic encephalopathy.
• Intake of NSAID followed by upper GI bleeding—erosive
gastritis.
• Burn or other major physical illness with upper GI
bleeding—stress ulcer.
• History suggestive of acid peptic disorder followed by
upper GI bleeding—peptic ulcer.
• Upper GI bleeding with bleeding from other sites-
bleeding/coagulation disorder.
• Repeated upper GI bleeding in young individuals
without any deterioration of general health—arterio-
venous malformation in the gastric wall.
Hematochezia/Bleeding per Anum

This means passage of altered blood per anum, at times it is
also used synonymously as bleeding per anum. Altered
blood means it is neither fresh blood nor tarry blood as in
melena. But from the patient’s point of view it may not be
possible to distinguish bleeding per anum and passage of
altered blood. True bleeding per anum means passage of
frank blood which may be complained as passage of blood
in drops or jets or streaking of blood on the surface of stool.
This blood if stays on the pan for some time will clot. This is
seen in ano-rectal pathology like piles, fissures, rectal
carcinoma, and rectal polyp. Piles is usually painless unless
complicated (thrombosis or infected), bleeding often follows
passage of stool in drops or jets; complaint is often there for
a long time. Recent constipation with frank bleeding per
anum suggests carcinoma rectum. Blood streaking on the
surface of formed stool and associated with painful
defecation is indicative of fissure. In case of a child with
bleeding per anum it is usually rectal polyp. In cases of
bleeding per anum it is required to exclude bacillary/ amebic
dysentery. I have seen cases of bleeding piles being treated
as bacillary dysentery and vice versa. A detail history and
visual inspection of the stool will be decisive in most of the
cases unless both the conditions coexist.
Altered stool occurs if the bleeding is from below the
ligament of Treitz and above rectum. Some of the causes of
hematochezia are bleeding in enteric fever, bleeding from
intestinal polyps, mesenteric artery occlusion, bleeding from
Meckel’s diverticulum, carcinoma colon, ulcerative colitis
and so on. It can also occur in association with upper GI
bleeding with hurried intestinal transit.
DYSPHAGIA
Dysphagia means difficulty in swallowing. It may be to
solid or liquid or to both. Patients might complain differently.
Some say a sensation of sticking of food while swallowing;
some say the feeling of a lump in the throat, some say they
are only able to swallow with a draught of water and so on.
The site of difficulty they complain is also variable, either in
the throat or inside the chest depending on the site of lesion.
The sense of a lump in the throat if not associated with true
difficulty in swallowing. This should not be considered as
true dysphagia. One should not confuse dysphagia with
refusal to take food which is seen in rabies, tetanus and
hysterical conditions. In conditions of odynophagia (painful
deglutition) there can be refusal to take food also. Whenever
dealing with a case of dysphagia the following points are to
be clarified. They are:
• Whether it is mechanical dysphagia (the lumen of the
esophagus is narrowed) or it is motor dysphagia
(coordinated contraction of the esophageal muscles is
lacking).
• Is it painful (odynophagia)?
• At which phase of deglutition is it felt?
• What are the associated complaints?
• How it has started?
In mechanical dysphagia there occurs dysphagia to
solid foods initially, which may be helped by a draught of
water, but in the late stage there will be dysphagia to liquids
as well. In motor dysphagia there is dysphagia to liquid
and solid from the beginning. A typical pattern of dysphagia
is seen in scleroderma. Here the patient complains of
dysphagia to solid in all postures whereas there will be
dysphagia to liquid only in recumbent posture, not in
upright posture. Some of the common causes of mechanical
dysphagia are carcinoma, stricture, compression of the
esophagus from outside (as in lymphoma, bronchogenic
carcinoma and aortic aneurysm, etc.). Some common causes
of motor dysphagia are achalasia, scleroderma, and diffuse
spasm of the esophagus, Chagas’ disease, and motor
neurone disease.
Painful dysphagia occurs in peritonsillar/tonsillar
abscess, retropharyngeal abscess; can also be seen in
esophageal candidiasis.
Dysphagia occurring in the initial phase of deglutition
(oropharyngeal) may be due to mechanical cause, but more
frequently it is of neurogenic in origin. There is non-
contraction/uncoordinated contraction of the pharyngeal
muscles, upper esophageal sphincter or of the striated
muscles in the upper oesophagus, which may be due to
nuclear or infranuclear involvement of the vagus nerve (with
or without ninth nerve). Involvement of bilateral corticobulbar
fibers can cause dysphagia (pseudobulbar palsy), but
unilateral lesion does not cause any problem. In such
conditions there will be associated complaints like dysarthria
and dysphonia. Nasal regurgitation of food/drink, induction
of cough on deglutition occurs mostly in lower motor neurone
type of bulbar palsy. If a patient does not have dysphagia/
dysphonia/dysarthria but attempt to swallow induces cough
think of the possibility of tracheo-esophageal fistula.
Dysphagia in other parts of the esophagus is more often
mechanical. Often the patient is able to locate the site of
dysphagia which is more or less correct.
Onset and course of dysphagia also helps in reaching at
the diagnosis.
• Abrupt onset of dysphagia occurs in bolus impaction or
impaction of foreign body. Can also be seen in bulbar
palsy and following ingestion of corrosive agents.
• Progressive dysphagia of weeks to months duration
suggests carcinoma.
• Transient dysphagia occurs in inflammatory conditions.
• Long standing dysphagia of several months/years
duration can occur in stricture, esophageal ring and
motor dysphagia.
Past History in a Case of Dysphagia

History of radiation, intake of corrosive agents, acid reflux
suggests stricture.
DIARRHEA AND CONSTIPATION

Before collecting details of the history of diarrhea or
constipation, one should enquire about the usual bowel
habit of the individual because normal bowel habit varies
widely.
Diarrhea
In case of diarrhea the following aspects should be enquired.
• Duration
• Frequency
• Volume of stool
• Color and odor
• Associated complaints.
Diarrhea of Short Duration (less than 2 weeks)

Mostly here the cause is infective in origin; but may be due
to intake of toxic substances or drugs. If there is history of
intake of contaminated foods or drinks infective cause is
suggested. Many people might be suffering from similar
illness (epidemic/mini-epidemic). Always take history of
intake of any drugs. Many antibiotics (amoxicillin,
ampicillin, tetracycline, cephalosporins) can cause diarrhea.
If diarrhea is associated with fever it goes in favour of
infective diarrhea. Diarrhea with vomiting suggests toxin
mediated diarrhea; may be bacterial toxins also. In entero-
toxigenic diarrhea there is either no abdominal pain or slight
abdominal pain. In entero-invasive diarrhea there can be
fever and abdominal pain. Passage of blood or mucus
suggests invasive diarrhea. But even in invasive diarrhea
there can be watery diarrhea at the beginning. Passage of
little amount of stool with blood and mucus several times a
day (may be > 10 times) associated with tenesmus (painful
straining for defecation with passage of small amount of
stool) suggests bacillary dysentery. Fishy odour of stool will
be there in amebic dysentery. Melena and bloody diarrhea
has been already discussed. Always try to see the stool
yourself in doubtful situations.
Diarrhea of Long Duration (Chronic Diarrhea)

When diarrhea lasts for more than two weeks it is chronic
diarrhea. This may be persistent or intermittent. The causes
of such diarrhea are inflammatory, osmotic, secretory or
intestinal dysmotility.
Inflammatory: The conditions are regional ileitis, ulcerative
colitis and intestinal tuberculosis. There will be passage of
blood, mucus and/or pus. Constitutional symptoms of fever,
arthralgia/arthritis, weight loss may be associated. Features
of subacute intestinal obstruction (intermittent abdominal
pain, vomiting) may be present in intestinal tuberculosis
and Crohn’s disease. Intestinal tuberculosis may be
associated with tuberculous ascites. Due to protein losing
enteropathy there can be peripheral oedema in all these
conditions. Carcinoma of the proximal colon can cause
diarrhea and weight loss though it is not an inflammatory
condition.
Osmotic diarrhea: This is mostly due to maldigestion (due to
exocrine pancreatic insufficiency) or malabsorption. There
is no blood or mucus in the stool. Volume of stool is large,
floats on water and sticks to the lavatory pan (steatorrhea).
Weight loss is invariably present. Ask for any specific food
intolerance like milk (Lactose intolerance) or wheat products
(Gluten enteropathy).
Secretory diarrhea: Passage of watery stool episodically or
chronically can be due to secretion of a lot of fluid into the
GI tract under influence of certain GI hormones like gastrin
(Zollinger- Ellison’s syndrome), vasoactive intestinal
peptide (pancreatic cholera), and serotonin (Carcinoid’s
syndrome).
Some other causes are villous adenoma of the rectum. In
this condition diarrhea may be due to increased secretion
also. In medullary carcinoma of thyroid there can be chronic
diarrhea also.
Intestinal dysmotility: The causes are thyrotoxicosis, irritable
bowel syndrome (IBS), and long standing diabetes mellitus.
• In IBS there is no weight loss, no nocturnal diarrhea and
there can be alternate diarrhea and constipation.
• In thyrotoxicosis other features will be obvious.
• In diabetes other features of autonomic neuropathy may
be present.
Spurious diarrhea: Passage of small amount of formed stool
frequently can be due to incomplete evacuation. This is seen
in growth in distal colon leading to faecal impaction above.
It may be seen in cases of fissure-in-ano. The patient passes
a little amount of stool and due to pain the anal sphincter
goes into spasm and defecation stops. After some time, it
restarts again. This may give a false impression of diarrhea.
I saw a case of intussusception who presented with diarrhea
for more than 15 days. Colonoscopy showed it to be a case
of intussusception. The diarrhea seen here was not true
diarrhea.
Constipation
Though constipation is a common problem but rarely is it
the chief complaint. Often other symptoms are more
troublesome which draws the attention of the patient. If at
all at any time the patient presents with constipation as the
primary complaint, the most important point to be collected
is the duration. It may be of long duration or of short
duration.
Long Duration
If it is from very early childhood (new born stage) and it is
marked it could be Hirschsprung’s disease. Excluding
Hirschsprung’s disease other causes of prolonged
constipation are idiopathic, hypothyroid state, Parkinson’s
disease, Dementic states, other paralytic states like
paraplegia, Chagas’ disease and IBS. In IBS there can be
alternate diarrhea with constipation.
Short Duration
• Intake of food rich in animal protein can cause
constipation.
• Several drugs can cause constipation like antipsychotic
drugs, iron, calcium, codeine and other opium alkaloids,
calcium channel antagonists and others.
• Distal colonic obstruction can also present with recent
onset constipation.
• In anal fissure and in thrombosed piles there is pain
during defecation so that the patient is afraid of passing
stool which leads to constipation.
• Obstipation (no passage of flatus or feces) occurs in
intestinal obstruction.
WEIGHT LOSS
Weight loss is a common complaint in comparison to weight
gain. However, the amount of weight loss is often
exaggerated. One has to be certain that, there is true weight
loss. This has been already discussed how to assess true
weight loss. Once it is established that there is weight loss it
should be viewed seriously because invariably it is due to
organic diseases, some of them may be grave conditions.
Though it is being discussed in GI system it does not always
mean that the underlying condition is in the GI system. In
most of the situations the cause is obvious from the
associated symptoms. Some of the common causes and their
associated symptoms are as follows.
1. Polyuria, polyphagia, polydipsia—IDDM (Type I
diabetes mellitus).
2. Inability to take food (dysphagia)—Carcinoma
esophagus/stricture esophagus.
3. Not getting enough food—malnutrition. More
common in children, but can be seen in adult as well.
4. Inability to retain food (prolonged vomiting)—gastric
outlet obstruction.
5. Exophthalmos, goiter, increased appetite, excessive
sweating—thyrotoxicosis.
6. Prolonged fever, persistent cough, hemoptysis, etc—
tuberculosis.
7. Voluminous stool, foul smelling, sticky stool—
malabsorption state.
8. All malignancies are associated with significant
weight loss and most of them will be obvious from
the other symptoms. But always the primary may not
be obvious. In such situations the cause may lie in the
GI system (stomach, colon, and pancreas) and in
female it could be in the genital tract.
9. AIDS—it is invariably associated with weight loss.
Associated symptoms like prolonged fever, prolonged
diarrhea, and generalized lymphadenopathy with
history of multiple sexual exposures will suggest the
diagnosis.
10. Cirrhosis of liver—upper part of the body is emaciated;
lower part is bloated due to edema and ascites.
Few more conditions can cause weight loss but the
cause may not be too obvious, though meticulously taken
history will reveal important clues to diagnosis. These are
Addison’s disease, panhypopitutarism, over dieting,
anorexia nervosa, chronic infective conditions like subacute
bacterial endocarditis and amoebic liver abscess.
CHAPTER
16
History in
Genitourinary
Disorders
Before putting any hollow thing (like

a needle) into the body, look for its
patency.
Patients with urinary problem may present with the
following complaints as single or in combinations.
• Oliguria/anuria
• Polyuria
• Frequency of urination
• Pain
• Fever
• Hematuria
• Passage of whitish urine
• Lump
• Retention of urine
• Hesitancy, urgency, incontinence
• Swelling of the body.
OLIGURIA
When the urine output is less than 500 ml in twenty-four
hours it is called oliguria. This amount of urine output is
required to wash out the nitrogenous waste products
produced daily. This has to be objectively established by
asking the patient to measure the 24 hour urinary output.
Once it is established, enquire about the duration of
complaint.
Oliguria of short duration: If the patient has developed oliguria
over a short duration (within days) it suggests acute renal
failure. This may be due to prerenal conditions like
hypovolemia as seen in diarrhea, vomiting, acute massive
blood loss, burns etc. It may be due to renal conditions like
acute glomerulonephritis (AGN), involvement of the kidney
due to other diseases like complicated malaria, snake bite,
intravascular haemolysis, urate nephropathy, myeloma
protein nephropathy (light chain), myoglobin precipitation
History in Genitourinary Disorders 201
in the tubules as in rhabdomyolysis and so on. If oliguria
lasts for a few days and the patient continues to take water
as usual edema will develop. Oliguria due to AGN will be
accompanied by hematuria. In angioneurotic edema a
similar picture like AGN develops but here swelling of the
body develops early, oliguria if at all develops will be later
than swelling of the body (reverse of AGN). There will be no
haematuria in angioneurotic edema. In both there can be
dyspnea, but if there is stridor (due to laryngeal edema) it
goes more in favour of angioneurotic edema.
Oliguria of long duration: If the patient complains of oliguria
of longer duration (weeks to months) invariably it will be
associated with edema. Oliguria lasting for more than two
weeks and less than three months will suggest RPGN
(Rapidly progressive glomerulonephritis) and if the duration
of oliguria lasts for more than three months it is suggestive
of chronic renal failure. This differentiation may not be
possible from history only, it needs investigation.
ANURIA
There will be no urination in twenty four hours. True anuria
is extremely uncommon in medical situations. It is usually
due to obstructive uropathy; either the obstruction is at the
bladder neck or accidental ligation of both ureters during
surgery. Bilateral obstruction of ureter leading to anuria is
at times possible in retro peritoneal fibrosis. Bilateral
occlusion of renal vessels (both arteries/both veins) can
also cause anuria, which is equally uncommon. Hence it
can be concluded that in all cases of anuria urinary tract
obstruction must be excluded. If the obstruction is below
the bladder neck there will be fullness of the bladder which
is quite painful if the sensory system is intact (above S2, S3).
Even an unconscious patient becomes restless due to full
bladder. A full bladder is also easy to detect by inspection
and percussion. The obstruction to the bladder neck need
not be structural always; it may be physiological also, due
to impairment of neurogenic control (lesion in the spinal
cord or cauda equina). However, unilateral lesion may not
cause retention of urine; if at all for a transient period.
Retention of urine due to neurological cause is easy to
diagnose except in few situations like intramedullary lesions
in the early stage.
POLYURIA/ NOCTURIA
When the twenty four hour urinary output is more than
three liters it is said to be polyuria. Like oliguria this has to
be objectively assessed. Ask the patient to collect urine for
24 hours for a few days and confirm that there is polyuria.
Once it is established one should try to find out a cause.
Some of the common causes of polyuria are diabetes mellitus,
diuretic therapy, polyuric phase of acute renal failure,
diabetes insipidus, some forms of chronic renal failure,
compulsive water drinking (psychogenic polydipsia) and
a few more. So in the history collect the following data.
• Associated with polyphagia, polydipsia, susceptibility
to infections and others—diabetes mellitus.
• History of intake of diuretics, patient may not be able to
name the drugs; hence check the drugs/prescription
physically.
• Preceding history of oliguria—polyuric phase of acute
renal failure.
• Long-standing history of anorexia, nausea, vomiting and
swelling of the body—chronic renal failure.
It is not possible to come to a conclusion from history
about compulsive water drinking and diabetes insipidus.
Even with detail investigations it may not be possible to
differentiate these two conditions.
Nocturia is nothing but nocturnal polyuria. In the initial
stages of all causes of polyuria patient feels that he has to
get up more frequently at night to pass urine. Truly there is
polyuria both at night as well as at day time; but as the
patient has to get up from sleep frequently to pass urine, he
appreciates that urination is more frequent at night. No one
counts how many times he passes urine in day time. There
can be nocturia in conditions of frequency also and in
bladder neck obstruction due to benign hypertrophy of
prostate.
FREQUENCY OF URINATION
Frequency of urination is nothing but passage of urine at
frequent intervals. When it is associated with increased
volume of urination it becomes polyuria (discussed earlier).
In true frequency there will be passage of small amount of
urine at a time. There are several conditions where this can
occur, but the primary mechanism is an irritable bladder
which senses to be full even at a smaller volume. This is
commonly due to inflammation of the bladder wall as in
cystitis, but can also be due to neurological instability
(particularly increased tone of the trigone of the bladder
under influence of sympathetic nerves as happens just before
examination/interview). Frequency of urination may be due
to true reduction of the capacity of the bladder. This may be
due to inability to distend as seen in infiltration of the
bladder wall (malignant/tubercular) or growth inside the
bladder lumen.
PAIN
Various types of pain are possible in diseases of the urinary
system.
• Fixed pain in the flanks occurs in perinephric abscess
and pyelonephritis. In these conditions pain is severe
and is associated with high fever. Constant aching type
of pain in the renal angle is possible in obstruction at
pelvi ureteric junction.
• Colicky pain can be felt in ureteric obstruction. Typically
in ureteric colic pain starts in the loin and radiates to the
groin, inner side of thigh and to the genitals. The quality
of pain is like other types of colicky pain (described in
GI system)
• Dysuria—a type of discomfort felt during passage of
urine (often burning type) is felt in inflammation of lower
urinary tract. In inflammation of urinary bladder
maximum pain will be towards the end of micturition,
and in urethral inflammation maximum discomfort is
during the flow of urine or at the beginning.
• Dull aching suprapubic pain is felt when the bladder is
full, also in cystitis.
• Pain in the perineum or in the rectum may be due to
prostatitis or prostatic abscess.
FEVER
Fever in urinary disorders usually means infection.
However, fever can be due to renal tumors also; particularly
hypernephroma. Urinary tract infection is traditionally
classified into upper urinary tract infection and lower
urinary tract infection (bladder and urethra). In upper
urinary tract infection (pyelonephritis) fever is high,
associated with chill and rigor and there will be pain in the
renal angle. It has to be remembered that in chronic
pyelonephritis there may not be fever at all. In lower urinary
tract infection fever is usually low to moderate grade,
associated with dysuria, urgency, and dull suprapubic pain.
Prostatic abscess and prostatitis can present as pyrexia of
unknown origin. In prostatic abscess there will be pain in
the perineum.
HEMATURIA
In hematuria patient complains of passage of red-colored
urine. The colour of urine varies, depending on the amount
of blood present. It may be smoky if the amount of blood is
small and it may be frankly red if the blood amount is more.
Even there can be hematuria without change of color of the
urine as in infective endocarditis (microscopic hematuria).
All red urine need not be hematuria. It can be due to
hemoglobinuria also. Differentiation of these two conditions
depends on the chemical and microscopic examination of
the urine. In hemoglobinuria chemical test for blood will be
positive and RBC in urine will be absent. Hemoglobinuria
suggests intravascular hemolysis. Ask the patient in which
phase of urination he notices hematuria. If it is in the initial
phase the cause is likely to be in the urethra, if it is in the
terminal phase the likely cause is in the urinary bladder
and if the hematuria is uniformly through out the act of
urination (total) the likely site of bleeding is in the kidney or
ureter. If the patient is not able to tell he can be asked to
collect urine in three clear bottles from initial, middle and
terminal phase of urination and you can see yourself. In a
case of hematuria few more points can help the diagnosis.
These are—geographical area, history of trauma, duration
and associated complaints.
Geographical area: In a tropical country like India Filaria is a
common cause, in Egypt it may be due to Schistosoma
hematobium infestation.
History of trauma: Direct or indirect trauma to the kidney or
urinary tract can cause hematuria. Trauma may be road
traffic accident, fall from a height or blunt injury to abdomen.
Trauma to urinary tract may be due to catheterization or
instrumentation. Perineal injury can lead to urethral rupture
(at times the trauma may appear to be trivial).
Associated complaint: It is the associated complaints which
give maximum clue to the diagnosis in cases of hematuria.
• If there is bleeding from other sites: It could be a bleeding
disorder like thrombocytopenia (as in idiopathic
thrombocytopenic purpura), hypoplastic anemia or
acute leukemia. It may be a coagulation disorder also;
particularly excess of anticoagulants.
• Fever: If the fever is of short duration it may be cystitis, if
fever is of long duration it may be infective endocarditis,
hypernephroma, renal tuberculosis.
• Feeling of a lump: Hypernephroma and other kidney
tumors like Wilms’s tumor, polycystic kidney disease.
Unlike hypernephroma hematuria is late in Wilms’
tumor.
• Pain: Pain will be present in trauma, stone in the renal
pelvis or in the ureter. Passage of a clot through the ureter
(bleeding due to other causes) can also cause colicky
pain.
• Swelling of the body: If hematuria is associated with
swelling of the body it could be acute glomerulonephritis
(AGN) or some specific histological varieties of nephrotic
syndrome. Both can also be distinguished from history.
In AGN there will be oliguria and the total duration of
complaints will be short; whereas in nephrotic syndrome
urine output is usually normal and the duration of
complaints is longer.
• Chyluria: If hematuria is associated with chyluria there
are only a very few causes like Bancroftian filariasis,
tuberculosis and lymphoma.
• Hemoptysis: If hematuria is associated with haemoptysis
it could be Good Pasteur’s syndrome or renal
tuberculosis with pulmonary tuberculosis.
• Weight loss: Can be found in renal cell carcinoma or renal
tuberculosis; can also be seen in malignant bladder
tumors.
• Painless, profuse and paroxysmal hematuria is seen in
papilloma of the bladder. Painless recurrent hematuria
can also occur in Ig A nephropathy and thin basement
membrane disease.
PASSAGE OF WHITISH URINE

If a patient complains of passage of whitish urine it could
be due to pus, excess of phosphates in the urine or chyle.
Frank pus discharge per urethra can occur in gonococcal
urethritis; whereas passage of turbid urine commonly
suggests lower urinary tract infection. Passage of whitish
urine may be due to phosphaturia where particulate
materials can be seen in the urine, particularly in a long
standing catheterized patient. In chyluria urine is white.
Fat globules can be seen to be floating on the surface of the
urine. This has been discussed earlier.
LUMP
At times patient may come with complain of feeling of a
mass in the abdomen. The mass is invariably due to a kidney
mass or due to a full bladder (see retention). By the time
kidney is felt as a mass it is quite big. It may be due to renal
tumors, polycystic kidney disease or hydronephrosis. Renal
mass in childhood could be due to Wilms’s tumor. In most
of these situations there will be other associated complaints.
RETENTION/ HESITENCY
Retention of urine (Full bladder) is easy to detect as it is
painful unless patient has got loss of sensation above S2
and S3. Often he will be complaining of difficulty in passing
urine or no passage of urine; the mass will be a suprapubic
mass. Some common causes of retention of urine are
congenital posterior urethral valve, phimosis, benign
hyperplasia of prostate, carcinoma prostate, stricture urethra
and stone or tumor at bladder neck or below. All these are
primarily surgical conditions. Common medical cause of
retention of urine is interruption of nerve supply to the
bladder (bilateral). Before the patient develops retention of
urine he may appreciate difficulty in initiation of urination
or there may be dribbling of urine. Patient may take longer
time to complete the act of urination. This is applicable both
for neurological as well as for surgical causes. Retention of
urine in female due to surgical causes is relatively
uncommon. However, some conditions peculiar to females
that can cause retention are carcinoma cervix, big cervical
polyp, retroverted gravid uterus.
INCONTINENCE
This is the reverse of retention. Here the patient is not able to
hold urine so that he passes urine in his cloth. The basic
problem is lack of tone in the bladder neck (internal and
external sphincter of the bladder). Lesion is in the inhibitory
pathway; may be in the spinal cord, conus medullaris or
cauda equina. There are several types of incontinence like
true incontinence, overflow incontinence and stress
incontinence. Most often it is, neurological in origin, but
stress incontinence particularly in female need not be due
to any neurological lesion; usually it is seen following child
birth and in uterine prolapse. In male it can follow bladder
neck surgery. True incontinence may be due to injury to
external sphincter or may be due to urinary fistula.
SWELLING OF THE BODY

If a patient comes with complaints of swelling of the body, it
may be a cardiovascular problem (discussed earlier), kidney
problem, liver disease (discussed earlier), diseases of the GI
system (protein losing enteropathy) and a few other situations
where there is increased capillary permeability like
angioneurotic edema, wet beriberi, epidemic dropsy. So
whenever there is swelling of the body, exclude kidney disease.
Kidney diseases causing edema are acute glomerulonephritis
(AGN), nephrotic syndrome, acute renal failure (ARF), chronic
renal failure (CRF) and RPGN (rapidly progressive
glomerulonephritis). In AGN and nephrotic syndrome
swelling may appear first in the lower eye lid. In all except
nephrotic syndrome and some forms of CRF there will be
oliguria. Duration of oliguria may help to differentiate ARF,
RPGN and CRF. Other associated symptoms may also help.
SIGNIFICANT PAST HISTORY IN URINARY DISEASES

In a case with urinary disease several past histories may be
significant depending on the situation. Some of the examples
are given herewith.
• Hypertension—CRF.
• Tuberculosis—genitourinary tuberculosis
• Recurrent urinary tract infection—in CRF
• Sickle cell disease—nephrotic syndrome
• Skin infection—acute glomerulonephritis
• Diabetes mellitus—nephrotic syndrome, CRF
• Collagen diseases—nephrotic syndrome, CRF
• Gonococcal urethritis—stricture urethra
• Perineal injury—stricture urethra
• Exposure to nephrotoxic drugs—ARF, CRF
• Hypovolemic conditions (diarrhea, vomiting, burn,
massive blood loss)—ARF and so on.
FAMILY HISTORY
Though it is not very important in diseases of the urinary
system, it may be important in a few conditions like
polycystic kidney disease and Alport’s syndrome, hereditary
tubular disorders like medullary cystic kidney, medullary
sponge kidney, congenital nephrogenic diabetes insipidus
and others.
Personal history is not very important in most cases of
urinary disorders.
CHAPTER
17
History in
Hematological
Disorders
In clinical medicine don’t be satisfied
by seeing the flower (the obvious), try
to see the insect sitting over it (the
minutes); but missing the obvious and
seeing the minute is unpardonable.
Changes in the blood parameters are very common. Blood
parameters are modified almost in all disorders. These are
not hematological conditions. Primary hematological
conditions are related to the changes in the formed elements
of blood. These include disorders of white blood cells (WBC),
red blood cells (RBC) and platelets. Changes in them may
be either reduced or increased number of the particular cell
line. Increased WBC count is either leukocytosis or leukemia,
increased RBC count is polycythemia, and increased
thrombocyte count is either thrombocytosis/thrombo-
cythemia. Similarly, decrease in WBC count is leukopenia,
decrease in RBC/hemoglobin level is anemia and decrease
in platelet count is thrombocytopenia. At times all the three
cell—lines may decrease which is called pancytopenia.
Coagulation disorders are considered as hematological
disorders even if they are not disorders of the cell lines.
Examination of blood film with or without bone marrow
is essential for making a diagnosis of most of these
hematological disorders. History taking is extremely
important in evaluating cases with hematological disorders.
The common complaints related to hematological
disorders are:
1. Weakness/asthenia: Though this is mostly a non-specific
complaint, but it is a common complaint in anemic
patients. Initially it may be difficult to interpret, but as
severity of anemia increases patient may not be able to
do his daily activities. The rate of progress depends on
the rate of progress of anemia.
2. Dyspnea: Dyspnea (breathlessness) is usually the
complaint of cardiovascular disease or respiratory
History in Hematological Disorders 213
disease. But severe anemia can cause dyspnea mimicking
cardiovascular illness. Anemia when severe or anemic
heart failure can cause dyspnea. Elderly persons develop
features of heart failure at a higher level of hemoglobin
than younger individuals. Anemia can precipitate heart
failure in patients with stable cardiovascular illness. So
also the threshold of angina is lowered in cases of
coronary artery disease in presence of anemia.
3. Swelling of the body (edema): A patient of anemia can
present with swelling of the body with the development
of heart failure. Anemia alone ordinarily does not produce
swelling of the body. If it is associated with hypo-
proteinemia, of course it can cause edema. If these two
conditions are there together most likely the cause is in
the gastrointestinal tract, hypoproteinemia is either due
to malabsorption state or due to protein losing
enteropathy.
4. Abdominal swelling: Abdominal swelling in hemato-
logical conditions is mostly due to enlargement of the
liver or spleen or both.
• Liver enlargement starts from right costal margin and
later on it can occupy other parts of the abdomen. In
primary hematological conditions it is rarely too big.
It is seen in hemolytic anemia, lymphoid malignancies
and leukemia.
• Spleen swelling starts from left costal margin. Later
on, it may progress to other parts of the abdomen;
even it may cause generalized abdominal swelling.
Commonly it enlarges towards the right iliac fossa.
The situations where spleen is significantly enlarged
are either hemolytic anemias or leukemias. Sickle cell
disorder being a hemolytic condition is not associated
with splenomegally. Very large spleen (below
umbilicus) is found in:
• Thalassemia
• Chronic myeloid leukemia
• Polycythemia vera
• Hereditary spherocytosis
• Tropical splenomegally syndrome
• Myelofibrosis
• Hairy cell leukemia
• Chronic malaria and a few more.
In these situations the patient may complain of dragging
pain in the abdomen. More acute pain can occur due to
splenic infarction. Abdominal swelling can be rarely
due to abdominal lymph node enlargement. If so, this is
often due to non-Hodgkin’s lymphoma.
5. Lymph node enlargement: Patients with hematological
disorders may present with the complaint of enlarge-
ment of the glands commonly in the neck and armpit,
but rarely at other sites. These may be the only
manifestation of lymphomas (Hodgkin’s and non-
Hodgkin’s). Lymph node enlargement is more commonly
due to lymphatic leukemia (acute or chronic) than due
to myeloid leukemias. In acute forms often this is
associated with fever or bleeding diathesis. Lymph node
enlargement can cause obstructive symptoms. In thorax
it can cause superior mediastinal syndrome presenting
as puffiness of face, hoarseness of voice or stridor
(evidence of major airway obstruction. In the abdomen
it can cause feature of subacute or acute intestinal
obstruction.
6. Abnormal Bleeding: Tendency to bleed from different sites
is a common and often specific complaint of hemato-
logical disorder. Abnormal bleeding means:
• Excessive bleeding following injury
• Prolonged bleeding following injury
• Bleeding from multiple sites
• Spontaneous bleeding (without trauma) from skin or
mucous membrane
 Disproportionate bleeding (A minor injury might
cause bleeding which otherwise would not have
caused in the absence of bleeding diathesis)
It has to be kept in mind that all abnormal bleeding is
not due to hematological disorders. Abnormal
bleeding may be due to defect in the blood vessels
(vascular cause). Of the haematological causes it
could be due to defect in the platelet or defect in the
coagulation factors. Defect in the platelet may be
quantitative defect (thrombocytopenia) or qualitative
defect (thrombasthenia) or due to both.
The features of unusual bleeding due to platelet defect
are:
• Cutaneous bleeding in the form of petechiae, purpura,
ecchymosis
• Bleeding from mucous membrane in the form of
epistaxis, hematuria, hematemesis, bleeding from
gum, etc.
• Spontaneous bleeding
• Severe thrombocytopenia can cause bleeding into the
brain.
The common causes of platelet disorders are hypoplastic
anemia, acute leukemia, Idiopathic thrombocytopenic
purpura, hypersplenism and drug induced thrombo-
cytopenia.
The features of coagulation defect are:
• Bleeding into the muscle
• Bleeding into the joints
• Bleeding stops but rebleeds after some time. In case of
platelet defect rebleeding is not a common feature.
• Presence of trauma. Some amount of trauma is needed
for bleeding to occur in such cases. Of course the trauma
may not be always obvious.
7. Fever: Patients may present with fever in cases of
haematological disorders. The cause of fever may be
infective or non-infective. Infective fever is seen in cases
with neutropenia, which may be due to agranulocytosis
or may be a part of hypoplastic anemia. Infection in these
cases is usually seen in the upper respiratory tract, but
can occur in the lower respiratory tract. Fever in
neutropenic patients may suggest the onset of septicemic
process.
Non-infective causes of fever are seen in cases of
leukemia and lymphoma. Fever in such cases is
commonly low grade and often lasts for days together;
hence may present as pyrexia of unknown origin. In
these cases fever can also be due to infection. In
Hodgkin’s disease fever can occur in episodes and there
can be night sweats.
8. Neurological manifestations: Several neurological
problems can occur in patients with hematological
diseases.
a. Paraplegia: Hematological diseases presenting as
paraplegia can be due to:
• Collapse of vertebra as in multiple myeloma
• Leukemic deposits in the vertebral canal
• Leukemic meningeal infiltration
• Extra-medullary erythropoiesis in congenital
hemolytic anemia particularly in thalassemia.
b. Hemiplegia: May be due to intra-cerebral bleeding or
cerebral thrombosis as seen in polycythemia vera,
thrombocythemia, thrombocytopenia. Rarely
bleeding into the brain can occur in cases with
coagulation defect. Sickle cell disease can also present
with hemiplegia.
c. Neuropathy: Mononeuropathy, Mononeuritis
multiplex or polyneuropathy can occur in patients
with lymphoma or plasma cell disorders. Cranial
neuropathy is also possible due to leukemic
infiltration of the basal meninges.
d. Features of raised intracranial tension: Patients with
polycythemia, hypercalcemia due to multiple
myeloma, hyperviscosity syndrome and CNS
lymphoma can present with features of raised intra-
cranial tension.
9. Bone pain and Joint pain: Bone pain and joint pain could
be the primary complaint of hematological diseases. The
causes are:
• Sickle cell disease can present as bone pain due to
vaso-occlusive crisis.
• Low backache in elderly male is a common complaint
in cases of multiple myeloma. There can be
pathological fracture in these cases.
• In acute leukemia stretching of the periosteum due to
marrow expansion can cause pain. The small bones
are commonly involved. In children involvement of
the small bones at the wrist and ankle can be confused
as rheumatic fever. Due to the same cause there occurs
sternal tenderness in this disease.
10. Some rare complaints: In addition to these common
complaints some rare complaints are also seen. These
are:
• Growth retardation is seen in cases of congenital
hemolytic anemia.
• Disfigured face is also seen in cases of congenital
hemolytic anemia particularly thalassaemia.
• Chronic leg ulcers are also seen in cases of congenital
hemolytic anemia.
HISTORY OF PAST ILLNESS IN

HEMATOLOGICAL DISEASES
While taking history in hematological disorders some
significant past illnesses, past treatment etc are helpful. Let
us see a few:
• Viral hepatitis in hypoplastic anemia.
• Offending drug intake in hypoplastic anemia,
agranulocytosis, and drug induced thrombocytopenia.
The list of drugs can be obtained from text books. Cancer
chemotherapy is an important cause of all these.
• History of radiation in cases of hypoplastic anemia and
leukemia.
• Intake of anticancerous drugs might be the cause of
second malignancy.
• Severe or chronic liver disease in cases of abnormal
bleeding.
• Consumption anti-coagulants in cases of bleeding
disorders.
• Hemotoxic snake-bite, other serious illnesses, advanced
malignancy could be the cause of abnormal bleeding
due to DIC.
• History of chronic blood loss due to bleeding peptic ulcer,
GI malignancy, bleeding piles in cases of iron deficiency
anemia.
• Offending drug intake in cases of drug-induced
hemolytic anemia.
• Repeated attacks of malaria could cause large spleen
leading to hypersplenism which may be significant in
cases of anemia, thrombocytopenia or leukopenia.
• History of repeated blood transfusion in cases of
thalassemia.
• Repeated episodes of bone pain or other visceral pain
suggestive of sickle cell disease.
• History of excess blood transfusion within a short period
could cause abnormal bleeding due to decrease in ionic
calcium.
FAMILY HISTORY IN HEMATOLOGICAL DISORDERS

Few hematological illnesses are genetically transmitted.
• Hemophilia is transmitted by X-chromosome in a
recessive mode. So the males suffer. Enquire about
abnormal bleeding in other male family members. The
maternal side of the family should be searched for as
females transmit the disorder.
• Congenital hemolytic anemias are often transmitted
genetically though the expression is variable.
Thalassemia and sickle cell anemia are common such
conditions. Autosomal dominant mode of transmission
is seen in hereditary spherocytosis.
• Rare platelet function disorders (Glanzmann’s
syndrome) can also be genetically transmitted.
PERSONAL HISTORY IN HEMATOLOGICAL DISEASES

Personal history is not very significant in hematological
disorders.
• If some body is a vegan (does not take any animal
product) he is likely to suffer from megaloblatsic anemia
due to B12 deficiency, as plant products are deficient in
this vitamin.
• Bad cooking practice can lead to loss of folic acid from
food and can contribute to megaloblatsic anemia.
• Alcoholics are more likely to suffer from folic acid
deficiency.
MENSTRUAL AND OBSTETRICS HISTORY

Menstrual and obstetric history is very much required in
patients with hematological disorders.
• Menorrhagia might be the cause of iron deficiency
anemia.
• Menorrhagia might be due to bleeding disorder.
• Severe anemia due to any cause can lead to amenorrhea.
• Repeated childbirth and abortion can lead to iron
deficiency as well as folic acid deficiency.
• Pregnancy itself may be the cause of dimorphic anemia.
• Blood transfusion may be required in pregnant ladies
with severe anemia.
CHAPTER
18
History in
Unconscious
Patients
Plan, prioritize and know the cost

effectiveness of every test before
investigating any case.
It is my observation over the years that most of the students
get confused when they deal with an unconscious patient.
Any unconscious patient is a critically ill patient. Approach
to these cases must be clear, quick and rational. Like other
systemic illnesses the key point lies in the history taking
and meticulous examinations. Failing to do this may lead
to lot of unnecessary investigations and wastage of valuable
time, which may at times cost the life of the patient.
The common causes of unconsciousness are:
A. Head injury
B. Cerebrovascular disorders:
• Cerebral hemorrhage
• Cerebral thrombosis
• Cerebral embolism
• Hypertensive encephalopathy
• Subarachnoid hemorrhage.
C. Infective conditions affecting the brain:
• Encephalitis
• Meningitis
• Cerebral malaria
• Typhoid encephalopathy
• Brain abscess
D. Metabolic
• Uremic encephalopathy
• Hepatic encephalopathy
• Anoxic encephalopathy—hanging and drawning
• Carbon dioxide narcosis
• Electrolyte imbalance
— Hyponatremia
— Hypercalcemia
History in Unconscious Patients 223
• Coma in diabetes
— Hypoglycemia
— Diabetic ketoacidosis
— Hyperosmolar
E. Intoxication
• Alcohol (ethyl and methyl)
• Barbiturate
• Opium alkaloids
• Benzodiazepines
• Other antipsychotic drugs
• Antidiabetic drugs
• Organophosphorus compounds and others.
Majority of the cases will fall under these categories.
However there are some uncommon causes like myxoedema
coma, pituitary hemorrhage, advanced diffuse cerebral
atherosclerosis, hyperviscosity states, etc. While collecting
history in unconscious patients the following things are to
be remembered.
From whom to Collect History?

These patients are either not able to narrate their history or
tell in a confused manner. So history should be collected
from a person who was actually present at the time of
occurrence of the illness. He may be the spouse, father,
mother, servant, school teacher, colleague, classmate, room
mate and so on. If the incident occurred on the road the
person who attended him first should give the history.
Exclude Head Injury

The causes enumerated here are mostly medical causes
except head injury. Hence, while dealing with an
unconscious patient first exclude head injury. It is simple
on most of the occasions. Because there will be history of
direct injury to head and following which the patient lost
consciousness. But at times the trauma may be less obvious,
because it may be an indirect injury; for example a fall. Here
it is required to know whether the fall is first (head injury)
or the unconsciousness is first (stroke) which led to fall.
This can be established fairly well if the circumstances under
which fall occurred can be known.
Where the patient fell? Whether the place was dark or
lighted? Was there anything to stumble over? Was the place
slippery (as a bath room)? A person will not ordinarily fall
in a known place even in darkness unless the place is
slippery or there is something to stumble over. The size of
the object over which the patient stumbled over should be
sufficiently large or heavy to make him fall; so enquire about
it. The patient might have missed a step in a staircase and
fell which is possible in darkness. Considering these entire
points one should be able to decide that there was sufficient
reason for fall; so that fall is first and the unconsciousness
is the effect. So it could be head injury. Other points which
may help are.
• if there is sufficiently large swelling over scalp.
• if there is bleeding from the nostril or from external
auditory meatus.
After head injury is excluded look for the following points
to reach at a provisional diagnosis.
Was the Patient Absolutely Normal Before It

Happened?
An apparently normal person may become unconscious in
cerebrovascular disorders or due to consumption of poisons.
The hallmark of a cerebrovascular disorder is a focal
neurological deficit which can be better known by examining
the patient, but can be known if the attendants are able to
tell that the patient is not moving a particular limb/limbs.
This can also be noted by closely observing the patient while
history is being collected. See whether any particular limb
the patient is moving or not, the position of the limbs, the
position and movement of eyes However, there may not be
focal neurological deficit in hypertensive encephalopathy
and subarachnoid hemorrhage.
In case of consumption of poison ask the attendants to
search for open strips of tablets or empty bottles in the vicinity
of occurrence of the incident. These things might be left in
the room or might have been thrown out of the window.
Hence they should also be instructed to search the ground
against the door or window. I remember a medical student
who attempted to commit suicide who had hidden the open
stripes of tablets underneath her mattress (she consumed
glibenclamide and propranolol together).There might be
smell of the particular poison from the breath of the patient
as in alcohol and organophosphorus compounds. If intake
of certain drugs is suspected enquire if any of the family
members is taking some drugs for a long time like antidiabetic
drugs, antiepileptic drugs or any other. I remember a case
where the young child had accidentally consumed all the
iron tablets of the mother who was taking for her continuing
second pregnancy. This type of enquiry not only helps to
know the drug (poison) but the amount of it (by deducting
the number of remaining tablets from those supposed to be
present by that particular day). I also remember a lady
student who consumed phenobarbiturate tablets getting
from her room mate who was taking for epilepsy.
What was the Starting Complaint?
Fever
Ask for history of fever before the onset of unconsciousness.
If the starting complaint is fever it is likely to be an infective
condition affecting the brain like encephalitis, meningitis,
cerebral malaria, typhoid encephalopathy. Encephalopathy
due to typhoid occurs after two to three weeks of continued
fever. If the fever is associated with skin rash it could be
viral meningoencephalitis and meningococcal septicemia.
It has to be remembered that fever can occur in other
conditions like intra cerebral haemorrhage/subarachnoid
haemorrhage, but in these conditions fever is not the starting
complain, fever occurs later; it is the loss of consciousness
which is the starting complaint.
Convulsion
If the disease started with convulsion it could be post ictal
state. Following repeated convulsions patient remains
unconscious for sometime. Hence the patient might be a
known case of epilepsy (either inadequately treated or
discontinued treatment). In a pregnant woman similar thing
can happen in eclampsia which is not difficult to diagnose
if blood pressure is recorded. This should be remembered
that convulsion can occur in almost all the causes of
unconsciousness mentioned above, but rarely in these
conditions it is the starting complaint.
Jaundice
If the patient had jaundice before becoming unconscious it
could be hepatic encephalopathy. If this is due to cirrhosis
of liver history suggestive of cirrhosis will be obtained
(ascites and leg edema of long duration, hematemesis) and
if this is due to hepatitis there will be jaundice of short
duration and if at all there will be edema or ascites it will be
of a few weeks or months (subacute hepatic failure). Jaundice
in an unconscious patient may be found in complicated
malaria and leptospirosis, but in these conditions rarely it
is the starting complaint, often other features dominate the
total clinical picture.
Headache
Headache might be the starting complaint in subarachnoid
haemorrhage or intracerebral hemorrhage; but headache is
the outstanding complaint (often it is bursting type) of
subarachnoid hemorrhage. Headache may be there in
meningitis and encephalitis also but in these conditions
fever occurs earlier or together. In subarachnoid hemorrhage
fever may occur later on, never the starting complaint.
Under what Circumstances it Happened?

• An otherwise normal person becoming unconscious
following exposure to hot weather (working/walking
under hot sun) could be a heat stroke; often the body
temperature of these patients is very high. Similarly,
prolonged exposure to too cold environment may cause
hypothermia; so the body temperature will be too low.
• A person recovered unconscious from a burning house
is likely to be suffering from carbon monoxide (CO)
poisoning. Similarly, CO poisoning can occur in persons
sleeping in a closed room with generator on.
• Drowning and hanging can cause loss of consciousness.
In these situations the circumstances which caused the
illness is obvious.
Was the Patient Receiving any Drug

before the Onset?
Look for the drugs the patient might be taking before
becoming unconscious. Not only see the prescription, verify
them physically too. Some drugs might be still there in the
pocket of the patient. These drugs themselves might be the
cause of unconsciousness or the underlying illness for which
the drugs were being taken might be the cause. Also verify if
the drugs have been taken as per the prescription or in
excess. The drugs might have been dispensed wrongly by
the chemist (so physical verification of the drug is important).
There are several such examples. I remember a case, where
it was prescribed to take DIMOL (antiflatulant) but the drug
served was DAONIL (oral hypoglycemic drug) which the
patient took and landed up in hypoglycemic coma.
A patient receiving diuretics for other illnesses may
develop confusional state due to hyponatremia.
Is there Any Other Specific Associated Symptoms?

Hyperventilation: If the patient is taking deep and rapid
respiration it could be uremic, diabetic ketoacidotic,
hyperosmolar coma or other forms of acidosis. Neurogenic
hyperventilation is also possible in situations with raised
intracranial pressure.
Excessive sweating: This may be due to hypoglycemia or in
cases where fever has just subsided in a febrile patient.
Polyuria: It could be the symptom of uncontrolled diabetes
mellitus and in some cases of chronic renal failure. In
polyuric phase of acute renal failure patient may develop
hyponatremic encephalopathy.
Oliguria: Irrespective of any cause if the patient has not
received sufficient water there will be decreased urination.
Hence before considering oliguria as a complaint patient’s
hydration status must be assessed. In spite of the hydration
status being good if the patient is oliguric it could be a case
of uremic encephalopathy (may be ARF, RPGN or CRF).
Swelling of the body: Loss of consciousness with swelling of
the body is possible in chronic liver disease (hepatic
encephalopathy), or kidney disease (uremic encephalo-
pathy).
Bleeding from other sites: Bleeding from other sites may be
due to a bleeding disorder which itself might have caused
intracerebral bleed. This may be due to leptospirosis as well.
Only upper gastrointestinal bleeding is not very important
because it can occur in several conditions due to stress
ulceration.
HISTORY OF PAST ILLNESSES

Hypertension: Look for the documentary evidences of
hypertension. Whether he was taking the drugs regularly
or discontinued before the onset of the illness (which is
fairly common). A patient of uncontrolled hypertension may
suffer from hypertension related conditions like
cerebrovascular accident (hemorrhage, thrombosis,
subarachnoid hemorrhage) or hypertensive encephalo-
pathy.
Diabetes mellitus: If the patient was a known case of diabetes
mellitus, ask for the documentary evidence for it and verify
whether he was continuing the drugs regularly or not,
whether hyperglycemia was well controlled or not.
Discontinuation of the drugs may cause diabetic
ketoacidosis or hyperosmolar coma. Was his diet habit
regular, particularly on the day of occurrence? Hypo-
glycemic coma occurs under the following situations.
• Taking the antidiabetic drugs and missing a meal or
taking less food.
• Wrongly taking excess of the drugs.
• Vomiting soon after intake of food.
One should be sure that diagnosis of diabetes mellitus
is reliable. I have seen cases being prescribed antidiabetic
drugs on detection of reducing substances in urine
(Benedict’s test) and patients presenting with hypoglycemic
coma.
COPD: If the patient was suffering from COPD (chronic
obstructive pulmonary disease) he might develop
confusional state due to excess of carbon dioxide (CO2
narcosis).
Hypothyroid state: History of hypothyroidism may be
obtained from the patient. If so how long the thyroxin has
been discontinued. Myxoedema coma occurs in patients of
long standing hypothyroid state, by which time the very
appearance of the patient may be suggestive of the diagnosis.
Chronic kidney disease: Any form of long-standing kidney
disease can cause chronic renal failure leading to uremic
encephalopathy.
Unconsciousness due to hypercalcemia and hyper-
viscosity is rare and often the underlying cause is more
obvious.
HISTORY IN PATIENTS WITH TRANSIENT

LOSS OF UNCONSCIOUSNESS
At times people present with transient loss of consciousness.
Some common causes of such problems are transient
ischemic attacks involving the vertebrobasilar territory,
syncope of different etiologies and Stokes Adams attacks
and epileptic attacks.
By far the commonest cause is syncope and the
commonest form of syncope is vasovagal syncope. The
circumstances under which syncope develops will be
decisive in most cases. For example, hearing a bad news,
seeing a frightening scene, prolonged standing under the
sun all can lead to syncope. Nausea is a frequent
accompanying symptom of vasovagal syncope. The other
type of syncope is micturition syncope which has a tendency
to occur repeatedly and each time during micturition, often
micturating in erect posture. Syncope of cardiac origin are
either arrhythmic or due to left ventricular out flow tract
obstruction. If it is due to arrhythmia (ventricular
tachyarrhythmia or marked bradycardia of any cause (sick
sinus syndrome, complete heart block) it can occur in any
posture. Remember that vasovagal syncope occurs in upright
posture. In case of syncope recovery is quick and often
complete. Rarely it may be associated with convulsion.
In case of transient ischemic attacks of vertebrobasilar
territory, there will be premonitory symptoms like vertigo,
diplopia and unsteadiness of gait before loss of
consciousness. Even these symptoms may persist for some
time after the patient regains consciousness.
In case of epilepsy recovery is often late and incomplete.
Following recovery patient may remain in an amnesic state
for some time, may feel undue tiredness and there could be
transient focal neurological deficit (Todd’s palsy). History
of tongue bite and involuntary passage of urine will go in
favour of epilepsy.
INDEX
A respiratory infections 116

Abdominal swelling 177 swelling of body 113
generalized 178 syncope 113
localized 177 menstrual history 122
Addiction and habituation personal history 120
alcohol 73 treatment history 121
drugs 75 Cerebrovascular disease 126
opium 74 Chaga’s disease 23
smoking 74 Chief complaints 27
Addison’s disease 22 chronological order 28
duration of complaints 42
B genuine nature 30
appetite 37
Bancroftian filariasis 24
breathlessness 35
Bowel and bladder 76
convulsions 33
C fever and chill 38
hematemesis 40
Cardiovascular disorders 107 hemoptysis 40
chief complaints 108 loss of consciousness 35
family history 120 poisoning 41
history of past illness 117 vomiting 38
history of similar weight loss 36
illnesses 117 recording 30
history of significant Collagen diseases 97
illnesess 117 Community history 67
history of present illness 109 Compressive myelopathy 145
chest pain 111 features 145
cyanosis 116 Constipation 196
dyspnea 109 long duration 196
fever 115 short duration 197
hemoptysis 115 Coronary artery disease 20
neurological deficit 115 Crohn’s disease 195
palpitation 114 Cushing’s syndrome 22
D melena 187
Demyelinating disease 126 probable cause 189
Diabetes mellitus 148 Gastrointestinal disorders 165
Diagnostic clues in a case of abdominal pain 166
fever 97 acute 167
associated complaints 99 chronic 175
degree of fever 106 Genitourinary disorders 199
duration of fever 98 anuria 201
Diarrhea 193 family history 210
long duration 194 fever 204
short duration 193 frequency of urination 203
Dysphagia 190 hematuria 205
past history 193 incontinence 209
lump 208
E oliguria 200
pain 204
Exercise 79 passage of whitish urine 207
polyuria/nocturia 202
F
retention/hesitancy 208
Familial clustering of swelling of body 209
diseases 66
Family history 63 H
genetically transmitted Hematological disorders 211
diseases 64
common complaints 212
autosomal dominant abdominal swelling 213
disorders 64 abnormal bleeding 215
autosomal recessive
dyspnea 212
disorders 65 family history 219
X-linked dominant
history of past illness 218
disorders 65 personal history 220
X-linked recessive History of past illness 55
disorders 65 diabetes mellitus 58
Food habit 72
hypertension 60
Friedreichs’ ataxia 21, 65
syphilis 61
G tuberculosis 59
significant illness 56
Gastrointestinal bleeding 187 similar illness 56
hematemesis 187 History of present illness 47
hematochezia 189 associated complaints 52
Index 235
breathlessness 53 eighth nerve 135
fever 52 eleventh cranial nerve
joint pain 53 136
swelling of body 53 fifth cranial nerve 134
negative history 54 first cranial nerve 132
History taking 4 ninth, tenth cranial
importance 4 nerves 135
leading question 12 second cranial nerve 132
nonverbal seventh nerve 134
communications 16 third/fourth/sixth
sequence 11 cranial nerve 133
Hodgkin’s disease 216 twelfth nerve 136
Huntington’s chorea 64, 149 motor system 137
Hypothyroidism 22 sensory system 139
structures from history 128
I cerebellar lesions 131
frontal lobe 128
Infective fevers 93
occipital lobe 130
J parietal lobe 128
temporal lobe 129
Jaundice 185 Non-infective fevers 95
hemolytic 185
hepatocellular 186 O
obstructive 186
Obstetrics history 85
L P
Lymphoreticular Personal information 19
malignancies 97 age 20
geographical location 23
M
occupation 24
Marfan’s syndrome 64 sex 22
Marital status 78
Menstrual history 85 R
Respiratory disorders 151
N
chest pain 161
Nephritic syndrome 22 cardiac 162
Neurological disorders 123 chest wall 162
cranial nerves 132 respiratory 162
cough 152 U
dyspnea 156 Unconscious patients 221
long duration 156 causes of unconsciousness
short duration 157 222
fever 161 cerebrovascular
hemoptysis 158 disorders 222
renal causes 159 head injury 222
respiratory causes 158 infective conditions
past history 163 affecting the brain 222
cortical type of sensory intoxication 223
loss 142 metabolic 222
family history 164 history of past illnesses 229
hemisensory loss 142 chronic kidney disease
mono-neuropathic 230
type 140 COPD 230
personal history 164 diabetes mellitus 230
polyneuropathic hypertension 229
type 140 hypothyroid state 230
root type 140 starting complaint 226
sensory loss in patches convulsion 226
140 fever 226
tract type 141 headache 227
site of lesion 142 jaundice 226
transient loss of
S unconsciousness 231
Unilateral corticospinal tract
Sheehan’s syndrome 22 lesion 149
Sleep 75
excessive sleep 76 V
insomnia 75 Vaso-vagal syncope 51
reversal of sleep rhythm 76 Vomiting 181
Socioeconomic status 77 duration 181
Solid tumors 97 long duration vomiting 182
Spinal cord disease 145 short duration vomiting 181
Sydenham’s chorea 22
W
T Weight loss 197
Thyrotoxicosis 22 Wilms’ tumor 21
Treatment history 87 Wilson’s disease 65

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The Art of

Kashinath Padhiary MD FICP FCCP

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

The Art of History Taking

First Edition: 2004

Is there a need for such a book?

1. General Considerations .......................................... 1

Be a man first, then the doctor.

Importance of History Taking

History Taking—an Art

Sequence of History Taking

The Leading Question

From Whom History to be Collected?

Observing for Nonverbal Communications

With the observations of thousands

THE CHRONOLOGICAL ORDER

Let us Discuss a Few Examples

Example 2: A patient comes with the chief complaints of loss

Example 3: A case came with the complaint of hematemesis

RECORDING THE CHIEF COMPLAINTS

GENUINE NATURE OF THE COMPLAINTS

Fever and Chill

THE STARTING COMPLAINT

For eliciting any physical finding the

Circumstances Under Which the Disease Started

Swelling of the Body

When the clinical observation and the

HISTORY OF DIABETES MELLITUS

The simplest way to improve the

GENETICALLY TRANSMITTED DISEASES

Autosomal Dominant Disorders

Autosomal Recessive Disorders

X-linked Recessive Disorders

X-linked Dominant Disorders (Rare)

Food mediated diseases may be due to:

While examining any patient, take

Never leave a patient receiving blood

ADDICTION AND HABITUATION

The Respiratory Problems

The Cardiovascular Problems

Reversal of Sleep Rhythm

BOWEL AND BLADDER

The absolute Sciences in Medicine are

A patient developing a new

One must teach to maintain the flow

IS THE COMPLAINT GENUINE?

INFECTIVE FEVER OR NON-INFECTIVE FEVER?

If Associated with Prodromal Symptoms

If Associated with Chill and Rigor

Fevers of Long Duration

DIAGNOSTIC CLUES IN A CASE OF FEVER

Prevalence of the Febrile Illness in a Particular Locality

History of Recent Travel

Time of Onset of Fever

THE CHIEF COMPLAINTS

HISTORY OF PAST ILLNESS

History of Similar Illnesses

History of Significant Illnesses

Chronic Respiratory Illnesses

Before doing a lumbar puncture

NATURE OF THE LESION

Gradual Onset and Progressive Course

Space Occupying Lesions (SOL)