Oriented History Taking

(Questions you need to ask in each symptom and the reason behind your question)
By Falih Obaid Shamkhy
Part one : general history

Part two: specific history and differential diagnosis
2 Oriented History Taking by Falih Obaid Shamkhy
Contents
Subject Page number Subject Page number
General history Frequency
Identity 4 Polyuria/Nocturia
Chief complain/s 5 Urgency
History of present illness 6 Incontinence
Review of systems 7 Hematuria 54
Past medical and surgical Pain during intercourse
8
history (dysparunia)
menstrual and gynecological
9 Vaginal discharge
history
family history 9 Prostatic and testicular pain
Social and occupational history 10 Urethral discharge
Drugs history 10 Erectile dysfunction
specific history CNS
Cardio Vascular System Headache 55
Chest pain 12 Loss of consciousness 63
Dyspnea 15 seizure 58
palpitation 17 Visual disturbance 64
Syncope 19 Vertigo, dizziness and falls 65
Leg swelling 21 Limbs weakness 61
Claudication 24 Locomotor system 67
Respiratory system Joint pain 68
Cough 26 Joint swelling
sputum 27 Stiffness
Hemoptysis 29 Muscle weakness
wheeze 31 Joint locking
strider 32 Deformity
Dyspnea 15 Myalgia
Leg edema 21 skin
Chest pain 12 Itch (pruritis)
GIT Skin rash 71
Vomiting 33 others
Diarrhea 35 fever 72
constipation 38 pallor 74
Abdominal pain 39
Anorexia
Dysphagia Odynophagia 42
Hematemesis 45
Melena 46
Rectal bleeding 47
Jaundice 48
Wt. loss
Abdominal distention 51
Wind
GUS
Loin pain 53
Dysuria
Part one:
General history
Identity (demographic details)
1. Name: You should record the patient's name, his father and grand father's name and if possible family name.
Sometimes patient's first name and middle (father) name will be similar to other patient, so you need to record a
grandfather and family name.
2. Age, date and place of birth: Certain diseases affect certain age group e.g. acute rheumatic fever affect
children while ischemic heart disease usually affect middle aged or elderly patient , dementia usually affects old patient
3. Sex: Sex linked recessive inherited disease for e.g. affect males only, like hemophilia A and B. while Females will be
carrier.
4. Religion:
5. Nationality: some diseases occur in certain nations like Shistosoma mansoni in Egyptians , malaria in Yemen
6. Marital Status and number of children: Married? Divorced? Separated? Widow?
depression is more common in a widow divorced or ' separated woman.
sexually transmitted diseases to the partner e.g. gonorrhea and hepatitis B
7. Next of Kin (or source of information in children ): Next of kin identification is important
to inform of the history instead a critically ill patient and to receive the instructions about the patient's health
state
8. Occupation (ask about recent and previous job): work? Retire? Self-employer?
Sewage workers → leptospirosis
Butchers → brucellosis
Nurses and doctors with→ viral hepatitis B,C
Occupational Jung diseases are more common in farmers, pigeon breeders, cement or cotton factory
workers. An epileptic patient who is a driver especially long vehicle driver, should not allowed to drive a car
(by law) until he is free of fit for 2 years
9. Address: (Tel.no.) You might need to contact with him after his discharge or contact with his family at home
concerning his progress while still in hospital ,also reflects the environment in which the patient is living and liability to
acquire endemic diseases.
10. Time , date of admission and Source of referral: Whether referred from a private clinic· or
primary health care or from other hospital etc.
11. ABO and RH group:
Example of an identity:
Mr. (Mister) Mohamed Thamer Rahman Altai is seventy years old, living in Diwaniya/ Alaskan quarter. He is married and
had three daughters and two sons. He is a teacher. His next of kin is Ali Hussein Rahman Altai; his cousin. The patient is
admitted into the hospital on sixteenth of January 2009. Mr. (Mister) Muhsen Yaseen Kadhem Alali is fifty five years old,
living in Najaf/ Alnaser quarter, and is ummarried. He is a manual worker and his blood group is A positive. His next of kin
is Ali Muhsen Yaseen Altai; his son. The patient is admitted into the hospital on 7th of March 2009. Ms (Miss) Maha
Majeed Ali Alsalami is thirty years old, living in Baghdad/ Alamel quarter. She is Moslem and unmarried. She is a teacher.
Her next of kin is Salma Majeed Ali Alsalami; her sister. The patient is admitted into the hospital on seventh of September
2011 Mrs. (Mistress) Nora Josef Tomas is forty years old, living in Basra/ Alashar quarter. She is Christian, married and
had one daughter and two sons. She is a house wife. Her next of kin is Yara Josef Tomas; her sister. The patient is
admitted into the hospital on sixteenth of February 2010.
Chief complaint/s
Chief complaint /s and its duration : the complaint which made the patients come to the doctor in a
private clinic, primary health care or hospital
Example : frequent bowel motion for 2 days before admission
NB. Use patient's own wording and not medically correct terms
Medical terms Patients description Medical terms Patients description

Headache Headache Diarrhea Frequent bowel motions
Fever Fever Constipation Inability to pass stool
Coma Loss of consciousness Obstipation Complete constipation with no passage of either feces or
gas
Terminal Difficulty in stopping micturition Jaundice Yellowish discoloration of the skin, mucous
dribbling membrane and sclera
Dyspnea Shortness of breath (SOB) Melena Black tarry stool

Palpitation Awareness of heart beats Loin pain Loin pain
Chest pain Chest pain Frequency Frequent micturition
Edema Ankle or feet swelling Urgency Rapid desire for micturition
Cough Cough Dysuria Painful micturition
Vomiting Vomiting Edema of face Puffiness of the face
Abdominal pain Abdominal pain Polydipsia Increased water intake
Hemoptysis Coughing up blood Odynophagia Painful swallowing
Cyanosis Bluish discoloration of the body Dysphagia Difficulty in swallowing
Retention Inability to pass urine Thyrotoxicosis Easy fatigueability
Lump A swelling e.g. in the abdomen Fatigue Generalized weakness of the body
Anemia Pallor of the skin Ascites Abdominal distension
Arthritis Limitation of joint movement Tenesmus Feeling of incomplete defecation
Hematemesis Vomiting up blood Hematochezia Bleeding per rectum or rectal bleeding
Dysgeusia Altered taste sensation Water brash Excessive salivation
Globus Feeling of a lump in the throat Polyphagia Increased food intake
Intermittent Pain in calf on walking Indigestion Discomfort after eating
claudication / Dyspepsia
Vertigo Sensation of unsteadiness Dizziness Sensation of faintness on standing
Hesitancy Difficulty in initiating micturition Regurgitation Return of food into the mouth
Anorexia Loss of appetite Pneumaturia Passing of gas bubbles with the urine
Cacageusia Foul taste in mouth Gynecomastia Breast enlargement in male
Heart burn Burning sensation in the chest Paresthesia Tingling sensation (numbness)
Halitosis Bad breath Xerostomia Dry mouth
Hiccups Hiccups or hiccoughs Convulsion Jerking movement of hands/face
Geophagia Desire to ingest clay Hyperhidrosis Excessive sweating
Pagophagia Desire to ingest ice Anismus Difficulty emptying the rectum
History of present illness
1- A known case of …? DM, HT, epilepsy etc.

2- Analysis of chief complaint
3- Review of system/s involved
4- Patient / family reaction
5- Hospital reaction
6- Progression in the health status of the patient in the form of improvement or
worsening since date of admission
7- Patient's condition now
Review of systems
Review of systems: The aim is to find by direct enquiry (closed questions), whether there are other
symptoms which the patient has not volunteered during history taking or forgot, to uncover symptoms or was
uncomfortable about to disclose during earlier in the history of present illness.
CVS: GIT:
1- Chest pain 1- Anorexia
2- Dyspnea 2- Abdominal pain
3- Claudication 3- Altered bowel motion (diarrhea or constipation)
4- Orthopnea 4- Flatulence
5- PND 5- Nausea & vomiting
6- Palpitation 6- Weight loss
7- Syncope 7- Haematemesis
8- Fatigue 8- Jaundice
9- Ankle edema 9- Dysphgia
10- Melaena
11- Bleeding per rectum
Respiratory system: GUT:
1- Chest pain 1- Dysuria
2- Dyspnea 2- Frequency
3- Cough 3- Nacturia
4- Sputum 4- Urgency
5- Haemoptysis 5- Urine retention
6- Wheeze 6- Polyuria
7- Stridor 7- Haematuria
8- Incontinence
9- Loin pain
10-Intermittent stream
11-Post micturition dripping
CNS: Locomotor system:
1- Headache 1- Joint pain
2- Dizziness 2- Joint swelling
3- Vertigo 3- Joint Stiffness
4- Visual disturbance 4- Joint locking
5- Syncope 5- Muscle weakness
6- Loss of consciousness 6- Deformity
7- Limb weakness
8- convulsion
9- Tremor
10-Paresthesia
7- Myalgia
Skin:
1- Petechiae
2- Echymosis
3- Itching
4- Skin rash
Past medical & surgical history
1. Pervious same symptoms or similar attack

2. Previous hospitalization (when, why)
3. Previous operation (when ,why ,name of hospital, complication etc.)
4. Previous blood transfusion (NO. of unit ,reason, complication)
5. Previous investigations and screening tests: tuberculin test, mammograms, stool for occult blood
6. Previous vaccinations
7. childhood Illnesses : ( measles , whooping cough , mumps , rackets , rheumatic fever )
8. Chronic illnesses : DM, HT, IHD, chronic renal diseases, asthma, epilepsy, Hepatitis, TB,SCA.
N.B The following relevant questions in the past history need to be asked initially in response to the
patient symptoms of presenting illness for example:
If the presenting
symptoms are Ask about previous:
suggestive of:
ischemic chest pain angina, MI , hypertension, DM. hyperlipidemia
infective endocarditis recent dental work, skin infection, penetrating trauma
previous similar attacks, hypertension, diabetes, angina, myocardial infarction;
rheumatic fever, previous bronchial asthma and tuberculosis, Previous DVT or
dyspnea pelvic surgery causing pulmonary infarction. Connective tissue diseases like
rheumatoid arthritis complicating to pulmonary fibrosis and effusion. Previous
malignancy, metastatic pleural disease, radiotherapy induced pulmonary fibrosis
Previous similar attacks, previous angina, myocardial infarction or rheumatic
palpitation
fever, or previous diagnosis of thyrotoxicosis.
Previous TB and bronchial asthma. Previous diagnosis of bronchiectasis,
cough childhood whooping cough and measles. Previous diagnosis of idiopathic
pulmonary fibrosis.
Previous hepatitis, previous attacks of jaundice, previous haematemesis or
jaundice
melaena. ,Previous blood transfusion. ,Previous abdominal surgery.
haematemesis or Previous similar attacks. , previous history of jaundice or hepatitis ( complicated
melaena to liver cirrhosis). , Previous history of duodenal or gastric ulcer.
Previous Jaundice (hepatitis), haematemesis, melaena, suggestive of portal

hypertension, Pervious tuberculosis causing TB ascites , Previous cardiac or
respiratory diseases which lead to ascites as a feature of congestive heart failure
abdominal distension
or corpulmonale for e.g. in patients with myocardial infarction, valvular heart
disease, cardiomyopathy and COPD , Previous renal diseases , Previous
abdomina1 surgeries causing adhesion and intestinal obstruction
Menstrual & gynaecological history
1. Gravida ? Para? +?
2. Age of menarche ? ( normal , Precocious puberty , primary amenorrhea. , secondary
amenorrhea. )
3. Menstruation Length (20-40) – period(3-7) – amount(30-80ml)
4. Dysmenorrhea ?
5. Menorrhagia
6. Inter-menstrual bleeding ?
7. Intercourse Dyspareunia (sup. or deep)
8. post-coital bleeding
9. Menopause
10. Post-menopausal bleeding (1 year after last period)
11. Abortions and miscarriages
Family history
1. Marital status (married, divorced ,separated ,widow)

2. partner : name ,age, occupation
3. children : No. ,age, sex, condition
4. father : name ,age, occupation
5. mother : name ,age, occupation
6. consanguinity: relative or not
7. Brothers & sisters(age ,sex, illnesses)
8. same symptoms in the family
9. Hx. of surgery in the family
10. History of death in the family :cause ,date
11. Diseases affect more than one member of the family
Examples of single-gene inherited disorders

Autosomal dominant
Adult polycystic kidney disease, Huntington’s disease, Myotonic dystrophy,
Neurofibromatosis
Autosomal recessive
Cystic fibrosis, Sickle cell anaemia, Alpha-thalassaemia, Alpha-1-antitrypsin
deficiency
X-linked
Duchenne muscular dystrophy, Haemophilia A, Fragile X syndrome
Social & occupational history
1. housing:
Own or rented house?
Water and electrical supply
Number of rooms
Sanitary condition
 Safety measures
2. Smoking: non? , active ? passive? Ex? (number ? type? Duration ? )
3. Alcohol drinking: Type ? Amount? duration? alcoholic liver disease
4. Animal relationship & Pet rearing: (bird fanciers - psittacosis) (brucellosis- cattle).
5. Hobbies?
6. Traveling?
7. worries or stresses?
8. contact with patient with same symptoms?
N.B.
Calculating pack - years of smoking
20 cigarette = 1 packet
Number of cigarettes smoked per day x Number of years smokes/20
For e.g. a smoker of 20 cigarettes a day who has smoked for 10 years would have smoked: 20 x 10/20 = l O
pack - years
Drugs history
1. Chronic drug use: steroid , contraceptive , Warfarin , Heparin , Aspirin, etc.

2. Allergy to drug & food animal hair, pollen or metal.
3. previous significant drug side effect
4. Over the counter medicines and herbal preparations
5. others : radiotherapy , psychotherapy
6. If there is a chronic disease controlled by special drug ask about:
 Name of the drug that the patient use

 Dose of the drug
 Duration of thereby
 Form of the drug
 Freq. of administration
 Rout of administration
 Who responsible for administration of the drug
 Any side effect
 Any new adjustment to the dose or type of the drug
 Storage of the drug
 Is the disease well controlled by this drug ?
Part two:
Specific history and DDX.

Cardio Vascular System
Chest pain
Ask about :
1. Site: central? Lateralize? Epigastric?
2. Onset: sudden? Gradual ?
3. duration : short? Long?
4. Character: heavy? Sharp? Tearing? Burning?
5. Severity: interfere with daily activity? Sleeping? Shouting? Levine sign?

Levine sign: When a patient with an anginal pain is asked to localize the sensation, he or she will typically place their hands over sternum,
sometimes with a clenched fist
6. Radiation: yes or not? Where?
7. Timing , progression , frequency: constant? Come in attack?
8. Aggravating and relieving factors: rest? nitroglycerin? breathing? Coughing? Cold? Excitement?
Exertion? Spacy food?
9. Associated symptoms: autonomic symptom? Fever? Cough? Dyspnea?
Past history:
previous heart attack (risk factor ), chronic bronchitis or asthma ( pneumothorax as complication), HT, DM : risk factors
Family history : of heart attack ( MI, angina ), recent death
Social history: smoking
Common causes of Chest pain

Cardiac causes MI, Angina pectoris, Pericarditis, Myocarditis, Mitral valve prolapse
Lung/ pleura Pulmonary embolism Pulmonary infraction, Pneumothorax, Pneumonia,

Malignancy, TB, CT disease
Esophagus Esophagitis, esophageal spasm, Mallory-Weiss syndrome
Mediastinal : Tracheitis, malignancy
Osteoarthritis, rib fracture costochondritis(Tietze syndrome )
(Musculoskeletal
intercostal muscle injury , Epidemic myalgia (Bornholm disease)
Cutaneous Herpes zoster
Aortic aortic dissection, aortic aneurism
Spinal prolapsed intervertebral disk
Chest pain Description
Anxiety /Site: Central , De
emotion retrosternal
– costa syndrome
Onset: gradual builds up chest pain never sudden
Nature: Tight squeezing, pressing, band like or heavy weight on the chest
Radiation: to arms, epigastric, neck and jaw
Duration: Longer than angina More than 30 min
Myocardial
Aggravating and relieving factors: precipitated by exertion(walking uphill), emotional
infarction
excitement, heavy meal and cold weather, but don’t relieved by rest or taking sublingual glyceryl
trinitrate
Associated symptoms: associated with autonomic symptoms like nausea, vomiting, diarrhea,
sweating and pallor
Same the MI but differ in : less sever , shorter( less than10min) , relieved by rest and TGN , not
Stable angina
associated with autonomic symptoms
Unstable Unstable angina is an angina precipitated by minimal exertion or at rest. The pain is of increasing
angina .severity, frequency and duration ( more than 10 min)
Prinzmetal
(variant) angina like pain which occurs at rest might result from coronary spasm
angina
anterior central pain or to the left of sternum Sharp, stabbing No radiation May be radiate to
trapezius muscle in pericarditis last hours worse on inspiration or lying(increase in venous return or
Pericardial
preload) , improves when the patient sits up and leans forwards, associated with fever
Aortic
Central retrosternal Sudden sever tearing to the neck and back between shoulder blades
dissection
Lateralize No radiation worse on breathing and coughing. with fever, cough, expectoration or
Pleuritic pain
dyspnea
Esophageal Central, retrosternal burning worsened by eating spicy or sour food or drink, lying at night, relieved
pain by antacids or cold drinks. odynophagia or dysphagia.
Mainly in the back, but may radiate round to front from thoracic spine, from vertebral collapse in a
Spinal pain
nerve root distribution, sometimes has a pleuritic quality
Neuro- due shingles (herpes zoster), a blistering scabbing and scaling rash , constant pain in nerve root
cutaneous distribution
musculoskele
localized No radiation worsened on stretching, turning, and tender on pressure
tal
Mediastinal
Central , retrosternal dull aching pain unrelated to respiration or cough
pain
Pain referred to medial aspect of the arm because of the involvement of lower root of brachia!
others
plexus (C8 cervical and Tl thoracic) as in pancoast tumour
N.B. Pain of pleurisy involving central part of diaphragm is referred to shoulder tip, and neck since the pain fibers from this part of
diaphragm run with phrenic nerve (C3, 4, 5), while parietal pleura covering the outer part of diaphragm is innervated through the thoracic
roots (intercostal nerve), the lower six of which are responsible for the supply of skin areas or the abdominal wall and back, pleural pain is
therefore frequently referred to the abdomen and lumbar regions
Example1 The condition repeatedly started gradually over few minutes as a moderately severe chest pain that was located in the
center of the chest when the patient walked more than 300 meters. Each time the patient felt it as burning pain, lasted 5 minutes, radiated
to the jaw and left shoulder, and associated with mild sweating and nausea. The pain however soon relieved with rest and sublingual
glyceryl trinitrate (GTN). The most likely diagnosis is stable angina. What is the
diagnosis if such a pain presents at rest or more severe than usual pain or occurs at lesser degree of exertion or at rest?
The diagnosis is unstable angina if such a pain presents at rest or is more severe than usual pain or occurs at lesser degree of exertion
or at rest.
Example2 The condition started gradually as a severe chest pain that occurred after heavy meal intake last night. The pain was
located in the centre of the chest, squeezing in nature, radiated to the neck and inner border of the left arm, and was accompanied by
nausea, two attacks of vomiting, and transient breathlessness. The pain experienced for the first time, persisted for 30 minutes and
relieved slightly by resting. The most likely diagnosis is myocardial infarction.
Example3 The condition started suddenly as chest pain that was located in the center of the chest slightly to the left of the sternum,
sharp in nature and catch the patient during coughing and inspiration, radiated into the neck, arms, and left shoulder, severe in intensity
but varies with movement and respiration, relieved by sitting up, and intensified by lying supine. The chest pain was preceded by low
grade fever for the previous one week and was accompanied by nausea and awareness of heart beats.
The most likely diagnosis is acute pericarditis
Example4 The condition started very suddenly as severe chest pain that was located in the upper part of the chest in the center,
sharp and tearing in nature, felt penetrating through to the back in the areas between the scapulae, very severe in intensity especially at
the start, and relieved only when seek medical advice and given injectable form of medication. The chest pain was associated with
profuse sweating and breathlessness. The pain was later felt in the back and migrating down with the time. This is the first time the
patient felt such a pain. The most likely diagnosis is aortic dissection.
Example5 The condition started two days ago as low grade fever, sour throat, and dry cough. The condition after that developed
gradually as chest pain that was located in the left of the chest anteriorly, persistent, Sharp and knifelike in nature, sometimes radiated to
the left side of the abdomen and back, severe in intensity, precipitated by breathing, coughing, and movements of the trunk, and relieved
by lying on the involved left side. The chest pain was associated with sense of breathlessness, and productive cough. The most likely
diagnosis is pleural pain from inflammation of the parietal pleura, as from pleurisy, pneumonia, pulmonary infarction, or
neoplasm.
Example6 The condition started gradually over the preceding one month as occasional attacks of chest pain that was located in the
center of the chest, variable in time, burning in nature, sometimes radiated to the back, variable from mild to severe in intensity,
precipitated by large meals and bending or lying down, and relieved by antacids medication and belching. The chest pain was associated
with regurgitation of sour material, no sweating or breathlessness. This is the first time the patient felt such a pain. The most likely
diagnosis is esophageal pain e.g. gastro-esophageal reflux disease (GERD).
Example7 The condition started gradually over the preceding two days as chest pain that was variable in location but often below
the left breast and along the costal cartilages, variable in time from few minutes to one hours, stabbing in nature, not radiated, mild to
moderate in intensity, aggravated by movement of the chest, trunk, and arms, and relieved by pain medications. The most likely
diagnosis is musculoskeletal chest pain.
Shortness of breath (dyspnea)
Ask about:
1. Onset : sudden? Gradual?
2. Duration: short? Long?
3. Timing: night? Early morning? Day?
4. Course: continuous? Episodic( respiratory)? Progressive( cardiac) ?
5. Severity: on rest ? on exertion, dgree? NYHA classification ?
6. Aggravating factors: position(orthopnea)? Exertion? environmental exposure? Allergen?
7. Reliving factors: position? Medication? O2 ?
8. Associated symptoms: review of the CVS and respiratory system
Character of dyspnea in:
Bronchial asthma: exertional or at rest or paroxysmal nocturnal associated with cough or wheeze, precipitated by allergens, relived
by bronchodilator, oxygen, no relation with postion
Chronic bronchitis and emphysema( COPD): exertional or at rest associated with wheeze and cough, patient sleeps well
but his dyspnea becomes worse on awaking in the morning
Pneumothorax: Sudden onset associated with unilateral pleuritic pain
Pulmonary embolus or infraction: Sudden onset associated with pleuritic pain, and sometimes with haemoptysis
Pleural effusion: Gradual onset, worse on lying on the normal side
Left ventricular failure: on exertion or on rest, lying flat or paroxysmal nocturnal dyspnea, left ventricular failure can present
suddenly as in acute pulmonary oedema or within several days or weeks associated with cough and frothy sputum
Pure mitral stenosis: Similar to left ventricular failure
Metabolic acidosis( Diabetic ketoacidosis, uremia, overdose of salicylate, lactic acidosis, ethylene glycol poisoning ) : Subjective
feeling of dyspnea due to hyperventilation
Other causes: Guillain Barre, obesity, Scoliosis, kyphoscoliosis, myasthenia

Acute dyspnea Chronic dyspnea

Cardiovascular Acute pulmonary edema Chronic heart
failure,
Myocardial
ischemia
Respiratory Acute exacerbation of asthma or COPD
COPD, Chronic asthma
Pneumothorax Interstitial lung
Pneumonia disease,
Pulmonary Chronic pulmonary
embolism thromboembolism, Bronchial
Acute respiratory distress carcinoma and lymphatic
syndrome Lobar collapse carcinomatosis
Laryngeal edema e.g. anaphylaxis Large pleural effusion (s)
Metabolic Diabetic ketoacidosis, uremia, overdose of Sever anemia
acidosis salicylate, lactic acidosis, ethylene glycol
Kussmaul poisoning
breathing
Psychogenic Hyperventilation (anxiety or panic-related)
Other Deconditioning in exercise Obesity
Example1 The condition started suddenly two hours after sleeping at night as SOB that woke the patient from sleep too terrible, was
so severe rendering him to stand up and open windows in attempt to get more air. The condition was associated with productive cough of
frothy pink sputum. His condition had been slightly improved by standing and using of oxygenation in his home until few minutes where
he asked for help and immediately rushed into the emergency unit of the nearest hospital. This attack was the third in this patient's course
of illness. The first attack was managed in the hospital and the second attack eased by sitting and medicine intake in home.
The diagnosis is acute dyspnea (paroxysmal nocturnal dyspnea) with pulmonary edema.
Example2 The condition started instantaneously as SOB one hour after playing basketball The attack was moderately severe made
him unable to continue playing; a little pit improved with resting in a sitting position, and was associated with anterior chest pain. When
the patient had noticed no complete improvement in his condition he asked his friends to be evacuated to the emergency unit of the
nearest hospital. This attack was the second attack in this patient's life; the first one had been encountered one year ago whilst the
patient was playing also and was managed in the emergency unit with the insertion of chest tube.
The diagnosis is acute dyspnea due to pneumothorax in patient with Marfan's syndrome. The patient was basket
ball player as he was tall hence Marfan's syndrome.
Example3 The condition started gradually as an exertional SOB that was experienced after walking for about 500 meters in the early
days of the patient's illness course. His condition had however deteriorated after few months and the SOB had been noticed with a lesser
degree of exertion such as walking for 300 meters. One year after that he started to become short of breath with daily activity like for
example bathing but activities like slow eating or talking slowly or resting did not result in breathlessness. His shortness of breath had
been constantly of moderate severity in the last days, was mainly worst in the morning on waking, slightly improved with the use of
inhalers, oxygen, and after coughing up sputum, and associated with small volume productive cough and wheeze. The patient had
noticed three separated attacks of so severe breathlessness in the last year that was experienced even at rest and necessitating hospital
admission The diagnosis is chronic dyspnea probably due to chronic obstructive pulmonary disease
.
Palpitation
Ask about:
1. Onset and offset: start and end suddenly? Gradually?
2. Regularity: regular( sinus rhythm, SVT, VT), Irregular(AF)
3. Specific description or feeling: sensation of missed beat, thumbing in throat, dizziness( anemia),
feeling of dying,
4. Speed: fast? Slow? (ask the patient to tap it )
5. Frequency of attack:
6. Duration of each attack:
7. Severity:
8. Aggravating factors: exercise, alcohol, coffee, tea, or cola, drugs( beta agonist), anxiety, or stress?
Position(palpitations that are positional may reflect a structural process within (e.g., atrial myxoma) or adjacent to (e.g., mediastinal
mass) the heart
9. Reliving factors: breathe holding, exercise, spontaneous, Valsalva maneuver, carotid massage, by
coughing, or by swallowing cold water or ice cubes
10. Associated symptoms: chest pain, dyspnea, polyuria, syncope(awareness of rapid palpitations followed by
syncope suggests ventricular tachycardia)
Past history: history of valvular heart disease or thyrotoxicosis
Common causes and patient description of palpitation

Causes patient description
Sinus rhythm (sinus tachycardia) : Healthy people are occasionally aware Heavy regular beats, that speed up and die
of their heart beating when they have normal (sinus) rhythm in the following down as when running upstairs, or notice at
conditions: physical or psychological stress, exercise, waiting for an time of stress or anxiety disorders
examination!, Slim people may notice it when lying on their left side,
excessive caffeine intake (tea, coffee, cola) and by nicotine from smoking.
Heart beat irregular, sensation of "missed
"or "skipped" beat or jumping into the throat
(thumping in my chest) This occurs because
Extra systoles(Ectopic beats): atrial and ventricular ectopic beats benign the ectopic beat produces a small
cause of palpitation at rest and are abolished by exercise often on rest or stroke volume due to incomplete left
lying down at night, made worse by smoking, alcohol, coffee or tea ventricular filling. The subsequent
compensatory pause leads to ventricular
overfilling and a forceful contraction with the
next normal beat.
Paroxysmal tachycardia (SVT, AF, VT, atrial flatter): Pathological rapid sudden onset of rapid heart beat " too fast
heart beat (tachyarrhythmia) starts suddenly, lasts for minutes or hours, and to count" may be regular as in SVT or
is unrelated to anxiety or stress. irregular as in AF, associated with chest
pain, dyspnea dizziness or syncope,
characteristically stops suddenly in SVT, but
often described as dying
Example1 The condition repeatedly started gradually over few minutes as unexpected awareness of heart beats that were regular,
so fast, and unrelated to specific positions. Each time the attack lasted 20 minutes and gradually disappeared in a spontaneous manner.
The attack was repeatedly recurred once the student awaiting her exam and disappeared after around 10 minutes once she engaged into
the exam The student had noticed no increase in urine volume during the attack and each attack was not followed by faintness or
lightheadedness The most likely diagnosis is sinus tachycardia
Example2 The condition repeatedly occurred whilst the patient at rest or went to bed as unexpected awareness of heart beats that
were irregular, infrequent, and unrelated to specific positions. The Patient initially felt missed beat as if his heart stopped what it was
doing but was followed by a particularly strong heart beat. The attack occurred repeatedly but infrequently and disappeared when the
patient started to walk or to exercise. The patient had noticed no increase in urine volume during these events and was not followed by
faintness or lightheadedness. The patient lastly was heavy cola, tea, and coffee consumer The most likely diagnosis is ectopic beats
Example3 The condition repeatedly started suddenly as unexpected awareness of heart beats that were regular, so fast described
by the patient as that my heart is fluttering, and unrelated to specific positions. The attack lasted 20 minutes and disappeared suddenly
when the patient used to introduce his right index finger into his mouth in a way of induction of vomiting. The patient had noticed an
increase in urine volume during the attack and each attack was accompanied by a sense of breathlessness but no loss of consciousness.
The attack happened twice monthly despite regular medicine intake described by the patient's physician The most likely diagnosis is
supraventricular tachycardia (SVT)
Example4 The condition started suddenly as unexpected awareness of heart beats that were completely irregular, so fast, and
unrelated to specific positions. The attack was described by the patient as that the heart is jumping and persisting up to the time of history
taking. The attack was accompanied by a sense of breathlessness and faintness that gradually faded with the time. The patient lastly was
heavy cola, tea, and coffee consumer The most likely diagnosis is atrial fibrillation (AF)
Example5 The condition started suddenly as unexpected awareness of heart beats that were regular and unrelated to specific
positions. The attack was described the patient as that the heart is fluttering too fast, persisting for around 5 minutes and was
accompanied by a sense breathlessness till he lost his consciousness The most likely diagnosis is ventricular tachycardia (VT)
.
Syncope (faint)
Pre syncope: feeling of impending loss of consciousness

Syncope: Is defined as sudden, transient loss of consciousness, but without features suggesting an epileptic fit, resulting from
inadequate cerebral blood flow and may be the result of variety of cardiac and non cardiac conditions
Coma: is defined as a persistent loss of consciousness due to disorder of the arousal mechanisms in the brain stem and diencephalon
and indicates bilateral hemisphere or brain-stem disease
Ask about:
1. Preceded by :
a-pre syncopal period (feeling of lightheadedness and near-collapse...):
b-palpation: suggests cardiac syncope like an arrhythmia as in VT, AF, less likely in SVT.
N.B: syncope might occur in prolong bradycardia as in sick sinus syndrome or . stokes- Adams attack
c-emotional stress, unpleasant sight: vasovagal syncope which is usually precipitated by parasympathetic nervous system
e.g. by pain, emotional upset, unpleasant sight, there is often a pre syncopal phase, where the patient is lightheaded, has
tinnitus and nausea, feels the vision is darkening
2. Frequency of attack:
3. Duration of each attack: In cardiac syncope, the patient rapidly recovers in less than one minute with
flushing while in vasovagal syncope, the recovery is often slow and there are nausea and lightheadedness.
4. Dose it occur at :
a-certain position: syncope which occurs on arising from lying or sitting position suggests postural hypotension.
B-during exercise: as in mitral valve stenosis and HOCM
c-during straining, coughing or micturition: usually occurs in an elderly due to decrease venous return.
D-turning head, or looking upward: due to inadequate brain circulation.
5. Associated symptoms: CNS and CVS

N.B. incontinence of urine can occur and there is often stiffening and brief twitching of the limbs, but tongue-biting never occurs
6. What are the symptoms that follow the syncope? It is rare for the syncope to cause injury and
there is no amnesia for events that occur after regaining awareness
Drug history: causing hypotension like nifidipine, amlodipine (vasodilators) and heavy diuretics (volume depletion).
Features helpful in distinguishing seizure from syncope (faint)

Seizure Faint
Aura (e.g. olfactory) + -
Cyanosis + -
Tongue-biting + -
Post-ictal confusion + -
Post-ictal amnesia + -
Post-ictal headache + -
Rapid recovery - +
Common causes of syncope

Cardiac Non cardiac
Obstructive Non obstructive Vasovagal syncope
Aortic stenosis Tachyarrhythmia: SVT, VT, AF
Carotid sinus syncope
Mitral stenosis Bradyarrythmias: 2°and
3°degree heart block Cough syncope
HOCM
Sick sinus syndrome Micturition syncope
Left atria tumors
Acute myocardial ischemia Drugs
Diabetic autonomic neuropathy
Example1 The condition started suddenly as a transient loss of consciousness whilst the patient was sitting The attack generally
lasted less than one minute during which the patient became dead-like and mildly stiff when the patient's son tried to shake him. The
condition was also associated with brief twitching of both upper and lower limbs, no incontinence of urine, and no tongue biting. The
patient rapidly recovered in less than one minute; feeling slightly lightheaded and having no nausea or headache. He immediately was
able to retain the events prior to this attack. He experienced that he had not consumed alcohol or used any medicine prior to this attack.
In addition, he had no SOB or awareness of heart beats but chest pain that was Such a presentation should raise suspicion of
cardiac syncope e.g. aortic stenosis If such an attack occurring in young adults during or after physical exertion and resulting
in death, what do you expect the cause The cause is probably hypertrophic cardiomyopathy
Example2 The condition started suddenly as a transient loss of consciousness whilst the medical student was standing looking at
pleural aspiration procedure. The attack generally lasted less than one minute during which the student became pale, sweaty, and mildly
stiff when his friends rushed to awake him. The condition was also associated with brief twitching of both upper and lower limbs, no
incontinence of urine, and no tongue biting. The patient slowly recovered in 5 minutes; feeling slight lightheadedness and nausea. After
that, he was able to retain the events prior to this attack. He experienced that he had not consumed alcohol or used any medicine but felt
lightheadedness and nausea prior to the attack Such a presentation should raise suspicion of vasovagal syncope
.
Ankle swelling or Body swelling in general
Ask about:
1. Site (localized or generalized) : ankle, leg, hand, scrotum, abdomen, face, periorbital
2. Onset: sudden, gradual?
3. Duration and progression: extend to other site?
4. Character: painful, painless? Itchy? Dusky, red? Pitting, non?
5. Severity:
6. Aggravating factors: drugs, walking, immobility, nutrition, sleeping, menstruation
7. Relieving factors: diuretics, sleeping, resting
8. Associated symptoms: local and systemic
Systemic:
-dyspnea, Orthopnea, chest pain or palpitation as in CHF -
Jaundice s&s of liver disease: hepatic cause -
variation in edema between day and night, Frothy and turbid urine: renal cause (nephrotic)
Local:
-Local tenderness and warmth: suggest inflammation.
-Local cyanosis: may signify venous obstruction.
-In individuals who have had repeated episodes of prolonged edema, the skin over the
involved areas may be thickened, indurated, and often red.
Causes of localized Oedema

Traumatic Fracture, sprains
Inflammatory Cellulitis, Boils, Abscess
Filariasis/ Post-operation /
Lymphatic Metastasis causing pressure on
Lymph Nodes
Venous Thrombosis, Varicose asymmetrical, (unilateral), and
Venous
Veins. often painful
Metabolic Gout
Cellulitis Painful associated with signs of inflammation
Rapture baker cyst Similar to DVT associated with knee arthritis
Immobility (hemiplegia)
Causes of not localized Oedema

cause example discerption
symmetrical, peripheral, bilateral, and
painless and associated with other features
of congestive heart failure,
CCF
Cardiovascular As heart failure progresses, the edema
Left ventricular failure
causes IVC. obstruction
may extend to the thighs and involve the
genitalia and abdominal wall and fluid may
collect in abdominal cavity (ascites) or .
thoracic cavity (pleural effusion)
Start from periorbital,
Renal causes Nephrotic syndrome, acute nephritis
Associated with frothy turbid urine,
difference between day and night
Nutritional causes Anemia, Hypoproteinemia,
Beri-Beri
Hepatic causes Cirrhosis of liver, Portal hypertension Start as ascites
The affected area may be red and
itchy (pruritic) because of local release of
Allergic causes Angioedema histamine and other inflammatory
mediators
Endocrine causes Myxedema
Nifidipine, amlodipine and
drugs
nonsteroidal antiinflammatory
Lymphatic Pelvic tumours
obstruction Milroy's disease ( congenital)
immobility Prolonged sitting during travelling
pregnancy Pressure of gravid uterus, Progesterone effect
occurs most commonly in women, typically varies with the menstrual cycle, and is
Idiopathic edema characterized by marked diurnal variation in weight (more than 1.5 kg over 12 hours).
N.B. generalized edema are: (fluid overload or hypoproteinemia)

Distinguishing them is performed by assessing the jugular venous pulse (JVP). The JVP is usually elevated in fluid
overload but not in hypoproteinemia
Fluid overload due to heart failure or renal disease, or from iatrogenic causes result from excessive fluid replacement
Hypoproteinemia, particularly hypoalbuminemia,

Hypoalbuminemia results from nephrotic syndrome (increased loss), liver failure (decreased synthesis), malnutrition and
malabsorption
Example1 During the early days of his illness course, the patient had noticed a swelling that initially involved the feet and ankles.
This swelling had progressed gradually to ascend up and involve legs, thighs and genitalia. The patient had noticed a particular difficulty
opening his eye on waking in the morning and in wearing his ring; his face was puffier than in the past. In the last days of his illness
course the patient claimed that all his body was swollen and that his weight started to increase. He had noticed no pain or bluish
discoloration of his swelling as well as no sense of breathlessness The diagnosis is generalized edema due to hypoalbuminemia
Example2 During the early days of his illness course, the patient had noticed a swelling that initially involved the feet and ankles.
This swelling had progressed gradually to ascend up and involve legs, thighs and genitalia; leg swelling is however became less
noticeable in the morning when the patient started to slightly raised his legs over night. The patient had noticed a particular difficulty
putting his feet in shoes in the evening. In the last days of his illness course the patient claimed that all his body parts was swollen and
that his weight started to increase; he got some improvement when he started to use a medicine made him urinate more than usual. He
had noticed no pain in his swelling but slight bluish discoloration of both legs as well as he started to experience sense of breathlessness
when walking and at night when sleeping The diagnosis is generalized edema due to fluid overload e.g. cardiac failure
Example3 The condition started three days after caesarian section operation when the patient had noticed left leg swelling
extending from the ankle joint to the knee joint. The swelling was slightly discolored blue and was painful that rendered her unable to
walk. The swelling was slightly improved when the patient raised her leg. The patient had noticed no change in the right leg and had not
experienced shortness of breath or chest pain The diagnosis is localised edema due to deep venous thrombosis (DVT)
Example4 The condition started gradually over many days when the patient had noticed entire right leg swelling that was non
painful, having normal color, and associated with heaviness like sensation in her abdomen especially in the inguinal region. The patient
had noticed no reddish discoloration of her right leg, no shortness of breath, and no chest pain but generally she felt weak and losing
weight The diagnosis is localized edema (lymphoedema) due to lymphatic obstruction
Example5 The condition started gradually over two days when the patient had noticed right leg swelling that was severely painful
rendering her unable to walk, reddish in color, and associated with hotness. This event occurred after the patient walked bare-footed for a
long distance. The patient had noticed no bluish discoloration of her right leg, no shortness of breath, and no chest pain but generally she
felt weak and febrile The diagnosis is localized edema (inflammatory) due to cellulitis
.
Intermittent claudication
Ask about:
1. Site: leg (one or both) or arm?
2. Onset: sudden, gradual?
3. Timing: (duration and course)?
4. Character: cramping, ill-defined, or bursting?
5. Reliving factors: bed hanging, walking, leg elevation, stooping forward, stop walking?
6. Aggravating factors: walking (determine the distance) or standing?
7. Associated symptoms: feeling of coldness, numbness, or pallor?
The clinical features of arterial, neurogenic and venous claudication

Arterial Neurogenic Venous
Pathology Stenosis or occlusion of major Lumbar nerve root or cauda Obstruction to the venous
lower limb arteries equina compression (spinal outflow of the leg due to
stenosis) iliofemoral venous occlusion
Site of pain Muscles, usually the calf but may Ill-defined. Whole leg. May be Whole leg. 'Bursting' in
involve thigh and buttocks associated with numbness and nature
tingling
Laterality Unilateral if femoropopliteal, and Often bilateral Nearly always unilateral

bilateral if aorto-iliac disease
Onset Gradual after walking the Often immediate on walking or Gradual, from the moment
'claudication distance' standing up walking starts
Relieving features On stopping walking, the pain Bending forwards and stopping Leg elevation
disappears completely in 1-2 walking. May sit down for full relief
minutes
Color Normal or pale Normal Cyanosed. Often visible

varicose veins
Temperature Normal or cool Normal Normal or increased

Edema Absent Absent Always present
Pulses Reduced or absent Normal Present but may be difficult to
feel owing to edema
Straight leg raising Normal May be limited Normal

Example1 The condition started gradually as a severe cramping pain that involve the left calf muscles when the patient walked to
more than about 500 meters. This pain rendered the patient unable to continue walking and so he stopped walking with the result of
prompt relief in less than one minute. The condition was however soon recurred once walking for further 500 meters was resumed. The
patient had noticed no rest/night foot pain or swelling of the left leg but had noticed that ascent for only one flight stairs brought up the
same pain The diagnosis is arterial intermittent claudication due to left femoropopliteal circulation ischemia
Example2 The condition started gradually as a severe cramping pain that involve the buttock muscles when the patient walked to
more than about 100 meters. This pain rendered the patient unable to continue walking and so he stopped walking with the result of
prompt relief in less than two minutes. The condition was however soon recurred once walking for further 100 meters was resumed. The
patient had noticed no rest/night foot pain or swelling of the legs but had experienced that lesser distance might produce the same pain
when he ascent up The diagnosis is arterial intermittent claudication due to aorto-iliac circulation ischemia
Example3 The condition started immediately as an ill-defined severe pain involving both legs when the patient stood up or started
walking. This pain was accompanied by pins and needles sensation rendered him unable to continue walking and so he stopped walking
and bended foreword with the result of pain relief although in the last days he had to stop walking and sit down to get relief. The condition
was however soon recurred once standing was resumed or walking was started. The patient had noticed no rest/night foot pain or
swelling of the legs but had experienced that descent from stairs produced the same pain
The diagnosis is neurogenic intermittent claudication
Example4 The condition started gradually as a mild bursting pain involving the whole left leg from the moment the patient started
walking. The pain then built up to reach higher intensity with continuing walking so that she stopped walking and sat down to get relief
although such an attempt was not always successful and the patient had to lie down and raise her left leg when isolated. The condition
was however soon recurred once walking was resumed again. The patient had noticed that her left leg is too blue in color and even mildly
swollen but there was no rest/night pain when she used to lie flat and elevate her left leg
The diagnosis is venous intermittent claudication
Example5 The condition started gradually as a severe foot pain 1 – 2 hours after sleeping that awoke the patient from sleep. In the
early course of his illness he had to hang his leg out of his bed to get some sort of gradual relief but his condition had deteriorated to the
degree that such maneuver had not resulted in pain relief. He tried then to walk for few minutes around his bed when the pain started; he
got some pain relief with this maneuver. Unfortunately however he stayed to have pain even with such a trial that made him slept in a
chair rather than in a bed to get some pain relief. Days after that he experienced foot pain not only at night but also with leg hanging,
walking around for few minutes with chair sleeping, and lastly even at rest The diagnosis is rest/night arterial ischemic pain
.
Respiratory system
Cough
Ask about:
1. Onset & Duration: short, prolonged or paroxysmal
short cough is usual in upper respiratory infection such as common cold.
Prolonged or paroxysmal coughing is characteristic of chronic bronchitis or asthma.
foreign body may be responsible for the abrupt onset of paroxysmal cough especially in children
2. Character:
dry or productive (if productive ask about sputum).
painful or painless,harsh barking or painful cough which suggests laryngeal inflammation.
Does it occur in bouts suggestive of whooping cough.
3. Timing: day time, night time, early morning?

If nocturnal causing sleep disturbance associated with wheeze suggestive of bronchial asthma or due to secretion running down the
larynx from the posterior nares in patient with chronic infection of the nose or sinuses or due to gastroesophageal reflux.
In COPD the patient sleeps well but has cough, dyspnea and wheeze, which becomes worse on rising in the morning and going to bed at
night
4. Reliving factors: drugs?
5. Aggravating factors: cold, dust or pollen, Perfume, certain positions, angiotensin converting enzyme inhibitor ?
Occurs during or immediately after swallowing of liquid which suggests neuromuscular disorder of pharyngeal muscles.
Occurs during working week days with wheeze and dyspnea which is relieved by weekend or during holiday suggestive of
occupational asthma.
6. Associated symptoms: sputum, hemoptysis, nasal discharge, fever, wheeze, stridor, leg edema, cyanosis, night
sweating, weight loss, rash, eczema, allergy, hoarse voice and bovine cough which suggests lung cancer involving left recurrent
laryngeal nerve
7. Severity:
Origin Common causes Clinical features

Pharynx Post-nasal drip History of chronic rhinitis
Larynx Laryngitis, tumour, Voice or swallowing altered, harsh or painful cough
Whooping cough, Paroxysms of cough, often associated with stridor
croup
Trachea Tracheitis Raw retrosternal pain with cough
Bronchi Bronchitis (acute) and COPD Dry or productive, worse in mornings
Asthma Usually dry, worse at night
Bronchial carcinoma Persistent (often with hemoptysis)
Lung Tuberculosis Productive, often with hemoptysis
parenchyma
Pneumonia Dry initially, productive later
Bronchiectasis Productive, changes in posture induce sputum production
Pulmonary edema Often at night (may be productive of pink, frothy sputum)
Interstitial fibrosis Dry, irritant and distressing
Sputum
Ask about:
1. Amount: small (a teaspoonful) or large (a teacupful)
large volume of purulent sputum, influenced by posture for several years suggestive of bronchiectasis.
Sudden production of large volume of purulent sputum on a single occasion suggests rupture of a lung abscess or
empyema into the bronchial tree.
Large volumes of watery sputum with a pink tinge in an acutely breathless patient suggest pulmonary edema
2. Color:
Mucoid (clear grey, white) in chronic bronchitis and asthma.
N.B: Thick viscid sputum which sometimes take the shape of bronchial casts occurs in asthma especially the kind
associated with bronchopulmonary aspergillosis.
Purulent (yellow or green) in bronchopulmonary infection, bronchiectasis or abscess
N.B: yellow sputum might occur in asthma without. bronchopulmonary infection due · to excess of eosinophils
Rusty as in pneumonia.
Serous (clear, watery, frothy) in alveolar cell carcinoma and acute pulmonary edema
3. Smell:
In abscess or bronchiectasis the sputum may sometimes have an offensive- smell due to infection with anaerobic organism.
4. Taste:
5. Contain blood: pure blood or mixed?
6. Variation with position: In patients with bronchiectasis purulent sputum is varying with posture
7. Associated symptoms: dyspnea, fever, weight loss, or night sweat?
Type Appearance Cause

Serous Frothy, pink Acute pulmonary oedema
Clear, watery Alveolar cell cancer (bronchorrhea)
Mucoid Clear, grey Chronic bronchitis/COPD
White, viscid Asthma
Purulent Yellow Acute bronchopulmonary infection (live neutrophils)
Asthma (eosinophils)
Green Longer-standing infection (dead neutrophils)
• Pneumonia
• Bronchiectasis
• Cystic fibrosis
• Lung abscess
Rusty Rusty red Pneumococcal pneumonia
Example1 The condition started five days ago when the patient had noticed burning and tickling sensation in the nose, blocked
nose, and watery yellow – green nasal discharge that persisted for two days. In the third day the patient had complained from short
painful dry cough with retrosternal chest pain and low grade intermittent fever. In the fifth day the patient started to have productive cough
of teaspoonful amount, not blood stained, yellow to green in color, and purulent. No particular position had been noticed to induce or
increase the cough that was so frequent, present all the time, slightly eased with cough syrup, and became associated with mild SOB and
higher grade fever with shaking chills The diagnosis is acute coryza (common cold) complicated by pneumonia
Example2 The condition started two months ago as low grade intermittent fever, night sweat, and cough. No particular position had
been noticed to induce or increase the cough that over the days of the first month was dry, so frequent, and present all the time; slightly
eased with cough syrup, and associated with SOB, low grade fever, and weight loss. The cough over the second month became
productive of teacupful amount; yellow in the start then became green in color with blood streaking and purulent
The diagnosis is post primary tuberculosis
Example3 The condition started two months ago as low grade intermittent fever, night sweat, weight loss with decreasing appetite
and cough. Sleeping on the left side had induced or increased the frequency of the cough that was productive, so frequent about twenty
times daily, and present all over the day but in particular at morning time; slightly eased with cough syrup, and associated with shortness
of breath. The sputum was yellow in the start of the illness course then became green and purulent with blood streaking, of copious
(teacupful) amount, and foul in smell and taste. Sleeping on the left side had increased the amount of sputum produced The diagnosis is
bronchiectasis
Example4 The condition started gradually one year ago as an exertional shortness of breath and cough. No particular position had
been noticed to induce or increase the frequency of cough that was present all over this time, so irritant, distressing, and frequently
encountered all over the day. Cough syrup had slightly eased the cough The diagnosis is pulmonary fibrosis
.
Hemoptysis
Ask about:
1. Is it true hemoptysis: or hematemesis, epistaxis
2. Amount: small, large, massive
3. Nature: frothy pink sputum, streaks of blood, or clear blood (bright red or dark red)
4. Duration:
5. Associated symptoms:
with large volume of purulent sputum over several years, which suggests bronchiectasis
Pink frothy and associated with acute dyspnea as in pulmonary edema
with sudden onset of dyspnea and pleuritic pain as in pulmonary infarction.
with purulent sputum, fever as in pneumonia
with fever, night sweats and weight loss as in TB or in lung cancer
NB: In cavitory TB, lung cancer, lung cavities containing mycetoma and bronchiectasis, haemoptysis can be massive
anti frank (coughing up pure blood) massive haemoptysis is defined as more than 500 ml of blood in 24 hours.
N.B. Because blood originating from the nasopharynx or the gastrointestinal tract (pseudohemoptysis) can mimic blood
coming from the lower respiratory tract, it is important to determine initially that the blood is not coming from one of these
alternative sites. Clues that the blood is originating from the gastrointestinal tract include a dark red appearance and an
acidic pH, in contrast to the typical bright red appearance and alkaline pH of true hemoptysis.
Causes of hemoptysis
Bronchial disease Parenchymal disease Lung vascular disease Cardiovascular disease Blood disorder
Acute bronchitis Tuberculosis Pulmonary infarction Acute left ventricular Leukemia
Bronchial adenoma Lung abscess Pulmonary renal syndrome: failure Hemophilia
or carcinoma Pneumonia • Goodpasture's syndrome. Mitral stenosis Anticoagulation
Bronchiectasis Trauma • Wegener's granulomatosis. Aortic aneurysm
Foreign body Parasite (e.g. hydatid • Microscopic polyangiitis.
disease) • Churg-Strauss syndrome.
• Cryoglobulinaemia
Example1 The condition started rapidly as burning and tickling sensation in the nose, blocked nose, and watery yellow – green nasal
discharge that persisted for one day. In the next day the patient had complained from irritating non productive painful cough that was
associated with wheeze, shortness of breath, and low grade intermittent fever. The cough after that started to produce scanty amount of
mucoid sputum. After that the cough started to be more copiers in amount and of mucopurulent blood-stained sputum over the next three
days. The blood was mixed with the sputum, four times daily for the next two days, little in amount, and bright red in color. The patient
was sure that the blood is the result of coughing and not vomiting or nose bleeding. The patient after that spontaneously recovered
The diagnosis is acute coryza (common cold) complicated by acute bronchitis
Example2 The condition started three months ago as low grade intermittent fever, night sweat, and extreme weight loss with
reduced appetite and cough. No particular position had been noticed to induce or increase the cough that was dry initially, frequent,
present all the time, slightly eased with cough syrup, and associated with shortness of breath. The cough then became productive of
scanty yellowish sputum with streaks of blood on the sputum over the preceding month. The sputum over the last two days started to
produce massive blood expectoration with sputum; two cupful sputum in a day The diagnosis is bronchial carcinoma
.
Wheeze
Ask about:
1. Onset & duration: episodic or continuous
2. Spontaneous or induced by:

exercise as in bronchial asthma
by drugs (B-b1ockers, aspirin) as in bronchial asthma.
occupation as in occupational bronchial asthma or occupational] lung disease.
3. Timing: At night as in bronchial asthma or after wakening in the morning as in COPD.
4. Associated symptoms: respiratory system

Strider
Ask about:
1. Onset: sudden or gradual
2. Duration:
3. Is the stridor exertional, biphasic, continuous:
4. Timing: (at night or day time)
5. Relieving & aggravating factors: (exertion, certain position)
6. Severity: cyanosis
Respiratory: fever, cough, chocking, runny nose, sore throat
Epiglottitis: high grade fever/dysphagia/drooling/toxic
DDX. Of strider:
a. Foreign body impacted in upper respiratory tract, e.g. In Larynx above the level of vocal cords
b. Angioedema (Allergic in nature)
c. Inflammatory lesions
1. Croup (acute laryngotracheo-bronchitis)
2. Epiglottitis
3. Diphtheria
4. Pharyngeal / retropharyngeal abscess.
d. Congenital lesions like Vascular rings, stenosis
e. Tumours-Papillomasetc.
f. Pressure due to Thyroid enlargement (Goitre)

Gastrointestinal tract
Vomiting
Ask about:
1. Preceded by nausea or not: If nausea precedes vomiting is usually due to disease of digestive system but nausea
without vomiting is most likely to be due to depression or neurosis, In raised intracranial pressure vomiting occurs without nausea
2. Onset:
Drugs, toxins, and gastrointestinal infections commonly cause acute symptoms,
whereas established illnesses evoke chronic complaints. Chronic nausea and/or vomiting with no other abdominal symptoms is usually
due to a psychological cause
3. Duration & frequency:
4. Timing: Early-morning vomiting is due to psychological cause, pregnancy, alcohol dependence, metabolic
disorders, and in case of increased intracranial pressure
5. Content:
Undigested food: Zenker's diverticulum or achalasia.
Blood: ulcer, malignancy, or Mallory-Weiss tear
6. Color:
yellowish or greenish: due to bile ( obstruction distal to pylorus)
bright red: if vomiting occurs soon after the hemorrhage
dark red (coffee ground): if the blood remaining in the stomach sufficiently long to be altered by acid and pepsin
whitish:
7. Odor: offensive, sour, feculent ?

Most vomit posses a sour odor due to acid present, but offensiveness usually indicates gastric outlet obstruction due to fermentation in
the retained gastric content.
In intestinal obstruction, the vomit may have feculent odor
8. Taste: better, sour?
9. Amount: small, large? (In gastric outlet obstruction, the vomiting is projectile of large volume with undigested
food taken many hours ago, not bile stained, since the gastric contents increase throughout the day to be vomited in
afternoon or evening.)
10. Projectile or effortless:

Projectile vomiting can be due to raised intracranial pressure or due to gastric-outflow obstruction
11. Reliving factor: drugs?
12. Aggravating factors: drugs or foods


upper abdominal pain: with or without hematemesis in peptic ulcer disease, cholecystitis and pancreatitis and misuse alcohol
unilateral headache: as in migraine.
anorexia and weight loss: as in gastric tumour or anorexia nervosa
diarrhea: as in gastro-enteritis.
abdominal pain, distension and absolute constipation: as in intestinal obstruction.
metabolic disease: like diabetes mellitus, uraemia, hypercalacaemia or Addison's disease
Fever:
Autonomic features: pallor, sweating and hyperventilation.
N.B. Relief of abdominal pain by emesis characterizes small-bowel obstruction whereas vomiting has no effect on
pancreatitis or cholecystitis pain
Infections CNS disorders Gastroduodenal disease
Gastroenterit Migraine Chronic peptic disease

is Hepatitis Raised intracranial pressure Gastroparesis e.g.
Urinary tract infection Meningitis diabetes, drugs Gastric
cancer
Drugs Acute abdominal disorders Psychiatric illness
Cytotoxic drugs Appendicitis Anorexia nervosa

Antibiotics Cholecystitis Bulimia nervosa
Digoxin Pancreatitis Depression
NSAIDs and opiates Intestinal obstruction
Metabolic Labyrinthine disease Others
Diabetic ketoacidosis Motion Any severe pain e.g. myocardial

Uremia sickness infarction Psychogenic
Addison's disease Labyrinthitis Alcohol
Malignancy
Diarrhea
N.B. firstly you should know WHAT IS THE CHARACTER OF THE NORMAL STOOLS?
The normal frequency of population ranges from three bowel movements per day to one bowel action every third day and a normal stool
consistency ranges from porridge – like to hard and pellety. The normal color of stool is brown color which is caused by stercobilin and
urobilin, derivatives of bilirubin. The odor is caused principally by products of bacterial action; these products vary from one person to
another, depending on each person’s colonic bacterial flora and on the type of food eaten.
Diarrhea: The passage of more than 250g of stool in 24h or frequent passage of loose stools.
Ask about:
1. Onset: (Abrupt onset= Infection or toxins), (days= Post gastrectomy /gut resection or after taking drugs like
Antibiotics, oral iron), (Sub-acute or chronic onset=Inflammatory bowel disease, colonic or rectal carcinoma,
malabsorption syndrome, pancreatic disease)
2. Duration: acute(less than 2 weeks) or chronic(more than 2 week)
3. Frequency: Passage of more than three loose bowel motions is abnormal
4. Timing: day time, nocturnal (Diarrhea occurring at night suggests organic disease)
5. Amount: large, small volume
6. Consistency: watery, bulky, greasy
7. Content: blood( mixed with or on the surface of the stool, or does it appear after passing the stool) , mucus, pus
8. Odor:
9. Color:
10. Aggravating factors: food consumption, raw milk
11. Reliving factors: fasting(Osmotic diarrhea stops when patients' stops eating or malabsorptive substance is discontinued,
while the secretary diarrhea will not stop on fasting ) , sleeping, or medications
12. Associated symptoms: abdominal cramps, pain(central=SI in origin or lateralize= LI in origin) ,

tenesmus(rectal involvement), fever, nausea and vomiting(gastrointeriitis), or arthralgia,
(fever, weight loss, borborygmi and wheeze suggestive of carcinoid syndrome),
Ask about s&s of hyperthyroidism, Adison disease
13. Severity: dehydration?

Some incubation period and stereotypical histories of infectious acute diarrhea

Incubation period
1-6 hours Staphylococcus aureus, Bacillus cereus
12-48 hours Salmonella, E. coli

48-72 hours Shigella, Campylobacter
> 7 days Giardiasis, Amebiasis

Stereotypical histories
Cholera Profuse watery diarrhoea
Severe dehydration resulting in weight loss
Giardiasis Prolonged, non-bloody diarrhoea
Shigella Bloody diarrhoea, vomiting, abdominal pain
Staphylococcus aureus Severe vomiting with short incubation period

Escherichia coli Commonest infectious agent amongst travelers
Watery diarrhoea with abdominal cramps and
nausea
Campylobacter A flu-like prodrome is usually followed by crampy abdominal pain, fever and diarrhoea which may be
bloody. Complication may include development of Guillain – Barré syndrome
Bacillus cereus Two types of illness are seen:
Vomiting within 6 hours, stereotypically due to
rice Diarrhoeal illness occurring after 6 hours
Amebiasis Gradual onset bloody diarrhoea, abdominal pain and tenderness that may last several weeks
Causes of abnormal stool appearance

Stool appearance Cause Stool appearance Cause
Fresh blood in or on stool Large bowel, rectal or Silvery Steatorrhoea plus upper GI
anal bleeding bleeding (pancreatic
cancer)
Stool mixed with pus Infective colitis or Rice-water stool (watery Cholera
inflammatory bowel with mucus and cell debris)
disease
Abnormally pale Biliary obstruction Black and tarry (melena) Upper GI tract bleeding
Pale and greasy Steatorrhoea Grey/black Oral iron or bismuth therapy
Small bowel Large bowel

Large amount, frequent of fluid diarrhea Small amount, frequent with urgency-
Without blood, mucus or pus- With blood, mucus or pus-
Malabsorpti on ( steatorrhea) foul smelly, - (Tenesmus (rectal involvement-
bulky, pale, floats on toilet pan or difficult to
flush away
Central abdominal pain- Lateralized pain-
Functional Organic
Associated with no blood or pus- With blood, mucus and pus-
Not at night- (Nocturnal (night diarrhea-
Associated symptoms (no fever or weight Associated symptoms ( fever and weight
(loss (loss
Example1 The condition started acutely over the previous two day as frequent loose stools. The bowel motion was watery at the
start and associated with abdominal discomfort and low grade fever. The motion then occurred 8 times per day, in both day and night
time, was yellow to green in color, was of small volume, and associated with passage of mucus and blood with it. His condition had been
associated with fever, abdominal cramps, and nausea and vomiting. The diagnosis is infective bloody diarrhoea e.g. shigellosis.
Example2 The condition started gradually over the previous one week as frequent loose stools. The bowel motions occurred initially
4 times per day and were associated with abdominal discomfort and low grade fever. The motion then occurred 10 – 12 times per day, in
both day and night time, was yellow to green in color, was of small volume and unformed, and associated with passage of mucus, pus
and blood with it. His condition had been associated with fever, abdominal cramps and feeling of incomplete defecation, and nausea and
vomiting. The diagnosis is infective bloody diarrhoea e.g. amebiasis
Example3 The condition started intermittently over the previous three months as frequent loose stools. Each time the attack
occurred over three days that was followed by a period of normal motion and then attack recurred again. The bowel motion occurred 5
times per day, in both night and postprandial time, green in color, of small volume, liquid unformed, and associated with passage of
mucus, pus and blood that was mixed with the stools. His condition had been associated with fever, abdominal cramps and feeling of
incomplete defecation. This attack was the 9th over these three months. The diagnosis is chronic bloody diarrhoea e.g. inflammatory
bowel disease (ulcerative colitis).
Example4 The condition started suddenly over the previous six hours as frequent loose stools. The attack involved the patient and
other six patients from the same region. The bowel motion occurred very frequent about 20 times over the previous six hours , rice-
watery, voluminous (large volume), painless and non offensive, liquid unformed, and was slightly cloudy with flecks of mucus but no
blood. His condition had been associated with muscle weakness and vomiting that followed the attack. There was no fever or abdominal
cramps. The diagnosis is acute watery diarrhoea; most likely cholera.
Example5 The condition started suddenly, four hours after food intake at restaurant as vomiting and frequent loose stools. The
attack involved the patient and his three friends who all ate processed meat and salad from the same restaurant. The bowel motion was
mild and occurred two times, was watery, small volume, liquid unformed, and was not associated with mucus or blood. His condition had
been associated with mild abdominal pain and severe vomiting. The diagnosis is probably staphylococcal food poisoning.
Constipation
Ask about:
1. Onset & duration: sudden or gradual (recent change in bowel habit, may indicate development of a malignancy.)
2. Frequency: How often do the bowels empty each week?
3. Characters of the stool: shape , color (Hard pellety stools occur with slow transit while loose watery stools are
associated with rapid transit. Both small pellety or very large stools are more difficult to expel than normal stools)
4. Aggravating or precipitating factors: food, stress or drugs causing constipation(Opiates, Anticholinergics,

Calcium antagonists, Iron supplements, Aluminum)
5. Reliving factors:
with abdominal pain, pain on defecation or rectal bleeding as in colorectal carcinoma.
with diarrhea without weight loss as in irritable bowel syndrome
with weight loss and bleeding per rectum as in carcinoma of colon
ask about s&s of hypothyroidism or Parkinson's disease
7. Severity: interferes with the patient's usual daily activities such as sleeping or eating.
Causes of constipation
Gastrointestinal disorders Non-gastrointestinal disorders
DIETARY DRUGS
Lack of fiber and /or fluid intake Opiates Iron supplements
Anticholinergics Aluminum –
Calcium antagonists containing antacids
MOTILITY NEUROLOGICAL
Irritable bowel syndrome Chronic intestinal Multiple sclerosis Spinal cord
pseudobstruction Cerebrovascular lesions
accidents Parkinsonism
STRUCTURAL METABOLIC /ENDOCRINE
Colonic carcinoma Diverticular disease Diabetes mellitus Hypercal
Hirschsprung`s disease Hypothyroidism cemia
Pregnanc
y
DEFECATION OTHER
Anorectal disease (Crohn's, fissures, hemorrhoids) Immobility Depression
N.B. Anismus/dyschezia means difficulty emptying the rectum despite prolonged straining while tenesmus means persistent urge to
empty the rectum with the feeling of incomplete evacuation.
Example1 The condition chronically started as months of infrequent passage of stools alternating with only brief period of frequent
loose stools. The patient had noticed passage of hard pellety narrowed-caliber stools that were associated with passage of mucus but not
blood or pus and were of normal color. The condition was exacerbated during stressful event and associated with belching, flatulence,
.and mild abdominal pain that were relieved with defecation The diagnosis is constipation – predominant irritable bowel syndrome
Abdominal pain
Ask about:
1. Site:
Visceral abdominal pain due to distension of hollow organs, excessive smooth muscle contraction, or mesenteric traction is poorly
localized pain while parietal abdominal pain and abdominal wall pain is well localized.
Pain which arises from stomach, pancreas, liver and biliary system is localized above the umbilicus,
Small intestinal pain is felt around the umbilicus etc..
2. Onset: sudden or gradual

(pain of perforation, ruptured abdominal aortic aneurysm or mesenteric infarction is sudden and severe)
3. Duration: esophagitis, peptic ulcer and irritable bowel syndrome cause chronic pain
4. Character: constant (steady), colicky, stapping, dull-ache, constricting (squeezing), pricking, tearing, heaviness…?
Constant pain: arises from solid organ as in pancreatitis or appendicitis.
Colicky pain: lasts for a short period of time, caeses off and then returns as in intestinal obstruction.
5. Radiation:
Urologic problem referred from right or left iliac fossa to the corresponding testis
Peptic ulcer referred from epigastrium to the back
Gall bladder problem referred from right hypochondrium to the right shoulder
Appendicitis Shifting from epigastrium where it disappeared then it appears in the right iliac fossa
N.B. shifting pain means perception of pain in new site whilst the initial site of pain disappeared. The term referred pain means
extension of pain to another site whilst the initial site of pain persisted
6. Timing: pain awaken the patient at night as in peptic ulcer pain
7. Progression: for example; In appendicitis, pain is initially localized around the umbilicus (visceral pain) and
spreads as the inflammatory response progresses to involve the right iliac fossa (parietal or somatic pain). If the appendix
ruptures, generalized peritonitis may develop. Occasionally, a localized appendix abscess develops, with a palpable mass
and localized pain in the right iliac fossa
8. Severity: pain interferes with sleeping, eating, or daily physical activity
9. Reliving factors: food in duodenal peptic ulcer, fasting in gastric peptic ulcer…
10. Aggravating or precipitating factors: fasting in duodenal peptic ulcer, food in gastric peptic ulcer…
Intermittent abdominal pain precipitated by eating: think of obstruction (gastric outlet, small bowel); pancreatitis; ischemic
bowel
11. Associated symptoms: GIT, GUT, other

heart burn: hot burning retrosternal pain which radiates upward and is associated with water brush(sudden appearance of excessive
saliva in the mouth),are features of gastro-esophageal reflux disease, due to reflux of the saliva. It may accompany pain of duodenal
ulcer.
fever, rigor, jaundice and change in colour of urine: suggestive of biliary disease.
Co-existing peripheral vascular disease, hypertension, heart failure or atrial fibrillation: may suggest a vascular disorder,
e.g. aortic aneurysm or mesenteric ischemia
haematemesis and/or melaena:
abdominal distension, absolute constipation and vomiting: intestinal obstruction.
weight loss: as in gastrointestinal malignancy
Some causes of abdominal pain

Surgical causes Medical causes
Appendicitis Peptic ulcer Abdominal aortic aneurysm Lead toxicity
Diverticulitis Diverticular disease Ischemic bowel Inflammatory
bowel disease
Cholecystitis Ovarian cyst Gastroenteritis Acute intermittent
porphyria
Pelvic inflammatory disease Aortic aneurysm Hepatitis Diabetic
ketoacidosis
Pancreatitis Intestinal obstruction Familial mediterranean fever Irritable bowel
syndrome
Pyelonephritis Biliary colic
Intra-abdominal abscess Uretric colic
Non-alimentary causes of abdominal pain
Myocardial infarction Dissecting Herpes zoster Cord Pleurisy Salpingitis or tubal
aortic aneurysm compression Diabetic pregnancy tis/ovary
ketoacidosis
Example1 The condition started gradually over eight hours as an abdominal pain that was poorly localized in the area surrounding
the umbilicus (i.e. Periumbilical) or some times in the area above it (i.e epigastrium), mild in intensity, cramping in nature, lasted 6 hours,
and associated with loss of appetite. The pain then SHIFTED to the right lower quadrant and became steady in character, more severe in
intensity, aggravated by motion or cough, and associated with nausea, vomiting, and loss of appetite
The diagnosis is acute appendicitis
Example2 The condition started gradually over few hours as an abdominal pain that was mild and tolerable discomfort at the start
but soon became severe in intensity, constantly steady and boring in character, located in the area above the umbilicus and the area
surrounding it, radiated to the back as well as to the chest, flanks, and lower abdomen, and associated with nausea, vomiting, and
abdominal distention. The pain was more intense when the patient lied supine, and patients often obtained relief by sitting with the trunk
flexed and knees drawn up. The patient gave a history of previous similar episodes all of which, like this attack, was precipitated alcoholic
binge The diagnosis is acute pancreatitis
Example3 The condition started as an abdominal pain that occurred in the mid-evening time of the last night The pain had followed
fatty meal intake and was moderately severe in intensity but rapidly increased to peak intensity and persisted over several hours,
constant in character, located in the right upper quadrant area, radiated to the right shoulder and right subscapular region, associated
with nausea, vomiting, and fever, and slightly relieved with pain medication The diagnosis is acute cholecystitis
Example4 The condition started as an abdominal pain that occurred in the mid-evening time of the last night The pain had followed
fatty meal intake and was mild in intensity at the start but rapidly increased to peak intensity, persisted over two hours, and then
spontaneously relieved. The pain was constant in character, located in the right upper quadrant area, radiated to the right shoulder and
right subscapular region, associated with nausea and vomiting. The patient had previous similar attacks The diagnosis is biliary colic
Example5 The condition started gradually as an abdominal pain that was well localised to the left lower abdominal quadrant,
intensely severe, cramping initially then steady in nature, lasted for hours radiated to the flank and back, eased with medicine, and
associated with loss of appetite, nausea fever, and inability to pass stools or even gas The diagnosis is acute diverticulitis.
Diverticulitis occurs when feces obstruct the neck of the diverticulum causing stagnation and allowing bacteria to multiply and
produce inflammation and called left-sided appendicitis. This can then lead to bowel perforation, abscess formation, fistulae
.into adjacent organs, or even generalized peritonitis
Example6 The condition started gradually as an abdominal pain that was severe in intensity, persisted over several hours, colicky
in character, located in the mid-abdominal area, aggravated by food intake and eased with medicine. The pain was associated with
vomiting, abdominal distension, and inability to pass stools or gas. One note the vomiting initially contained bile and mucus then became
feculent orange-brown in color with a foul odor. The patient had an old abdominal surgeryThe diagnosis is acute mechanical lower
intestinal obstruction. The mnemonic used for symptoms of intestinal obstruction collectively is PVCD where P refers to pain, V
.for vomiting, C for absolute constipation, and D for abdominal distension
Example7 The condition started over the preceding two years as recurrent abdominal pain that was variable in intensity from mild
enough to be ignored to severe interfering with daily activities apart from sleep variable in location e.g. left abdomen, right abdomen, or
lower part of the abdomen, frequently episodic and crampy bloating but mainly was constant in character, persisted over one to hours
exacerbated by eating, emotional stress, and premenstrual and menstrual, and improved by passage of flatus or stools. The pain was
associated with bloating and abdominal distention The diagnosis is irritable bowel syndrome
Example8 The condition started suddenly over the preceding minutes an abdominal pain that was diffuse all over the abdomen,
severe interfering with daily activities, constant in character, persisted over one to two hours, worse with movement, and slightly improved
by lying still. The pain was associated with nausea, vomiting, fever, and abdominal distention The diagnosis is ruptured viscus and
peritonitis
Example9 The condition started gradually over the preceding hours as an abdominal pain that was located in the left flank region,
initially of moderate severity but 20 minutes later became so severe, colicky in nature, persisted over one to two hours, radiated to left
groin and left testis, worse with movement that the patient cannot find a comfortable position, and slightly improved by pain medications.
The pain was associated with nausea, vomiting, painful micturition, and passage of blood in urine The diagnosis is renal colic due to a
stone that traverses the ureter. The vast majority of ureteral stones <0.5 cm in diameter will pass spontaneously
Example10 The condition started suddenly over the preceding half an hour as an abdominal pain that was located in the left lower
quadrant of the abdomen, so severe interfering with her daily activities constant and some times stabbing in character, persisted over two
hours, worse with any movement and slightly improved by pain medications. The pain was associated with nausea, vomiting, and
absence of menses for the previous two months and there was no radiation The diagnosis is ruptured ectopic pregnancy
,
Dysphagia
Ask about:
1. It’s true dysphagia? :
dysphagia: difficulty in swallowing
Odynophagia: pain on swallowing often precipitated by drinking hot liquid, is transient persists only during 15-30 seconds that a bolus
takes to traverse the esophagus.
Globus: is common, non painful sensation of a lump, fullness or tightness in the throat of unknown etiology, does not interfere with
swallowing and is not related to eating ( usually alleviated by eating)
Aphagia signifies complete esophageal obstruction which is usually due to bolus impaction and represents a medical emergency
Phagophobia: meaning fear of swallowing, and refusal to swallow may occur in hysteria, rabies, tetanus, and pharyngeal paralysis due
to fear of aspiration.
2. For what: for solids or liquids? or both? Which first?

Difficulty only with solids implies mechanical dysphagia with a lumen that is not severely narrowed. In advanced obstruction, dysphagia
occurs with liquids as well as solids.
In contrast, motor dysphagia due to achalasia and diffuse esophageal spasm is equally affected by solids and liquids from the very onset
3. Site: Oropharyngeal, esophageal(upper, mid, lower)

Oropharyngeal dysphagia refers to difficulty in either the initiation of swallowing or the transfer of food from the mouth into upper
esophagus, caused by neurological or muscular diseases including parkinson's disease, stroke, myasthenia gravis, motors neuron
disease involving the bulbar muscles.
4. Onset: acute or chronic
5. Duration & frequency:
6. Progression:
7. Reliving factors: water drinking, standing or sitting upright(motility disorders (e.g. achalasia or diffuse spasm)
8. Aggravating factors: history of foreign body ingestion, corrosive material?
When hoarseness precedes dysphagia, the primary lesion is usually in the larynx; hoarseness following dysphagia may suggest
involvement of the recurrent laryngeal nerve by extension of esophageal carcinoma. Sometimes hoarseness may be due to laryngitis
secondary to gastroesophageal reflux.
Hiccups may rarely occur with a lesion in the distal portion of the esophagus.
A prolonged history of heartburn and reflux preceding dysphagia indicates peptic stricture.
Unilateral wheezing with dysphagia may indicate a mediastinal mass involving the
esophagus and a large bronchus.
Severe weight loss is highly suggestive of carcinoma
Chest pain with dysphagia occurs in diffuse esophageal spasm and related motor disorders
Chocking or regurgitation of food through the nose during swallowing: oropharyngeal causes of dysphagia. This is caused by Jack of
coordination of the soft palates, which fails to close off nasopharynx during swallowing
cough, or sputtering after swallowing indicative of aspiration.
Whether there is need to swallow repetitively to achieve satisfactory clearance of swallowed material: oropharyngeal causes of
dysphagia.
vertigo, nausea, vomiting, and diplopia: symptoms of brain stem lesion
Raynaud's phenomenon and tight skin: consider systemic sclerosis.
10. Severity:
Example1 The condition started gradually over the preceding month as an intermittent difficulty in initiating swallowing. This
difficulty became most noticeable after prolonged chewing as in meat chewing, particularly experienced in the later hours of the day,
improved by rest and sleep, and associated with aspiration, chocking, disturbed speech, and muscle weakness. During the early hours of
the day, she had noticed that she was completely normal. The diagnosis is oropharyngeal dysphagia due to myasthenia gravis.
Example2 The condition started gradually over the preceding six months as a difficulty in swallowing. This difficulty was intermittent
in nature, most noticeable for solid food only where the food became sticking after swallowing at the mid sternum, eased by fluid intake,
and not associated with chest pain, aspiration, or chocking. Of note the patient had no prior history of heart burn, or concomitant complain
of muscle weakness. The diagnosis is esophageal dysphagia due to lower esophageal rings.
Example3 The condition started gradually over the preceding six months as a difficulty in swallowing. This difficulty was progressive
in nature noticed in early months of the illness course for solid food only Where the food became sticking after swallowing at the mid
sternum, eased by fluid intake, and not associated with aspiration or chocking during eating. The patient then developed difficulty to both
solid and liquid diet. Of note the patient had prolonged prior history of heart burn, regurgitation of sour material into the mouth, and
occasional chest pain. The diagnosis is esophageal dysphagia due to peptic strictures.
Example4 The condition started gradually over the preceding ten months as a difficulty in swallowing. This difficulty was progressive
in nature noticed for solid and liquid diet from the start where the food became sticking after swallowing at the mid sternum, eased
somewhat by standing and moving around during eating, worsened by emotional stress and hurried eating, and associated with difficult
belching, night cough, pulmonary aspiration, and weigh loss. The swallowing was not associated with chocking. Of note the patient had
no prior history of heart burn or concomitant complain of muscle weakness. The diagnosis is esophageal dysphagia due to achalasia.
GIT tract bleeding
Upper gastrointestinal tract bleeding (proximal to the ligament of Treitz) and manifest clinically as hematemesis,
melena, and sometimes hematochezia
Lower gastrointestinal tract bleeding (distal to the ligament of Treitz) and manifest clinically as
hematochezia and sometimes as melena
Hematemesis is defined clinically as vomiting up blood that may be red with clots when bleeding is profuse, or black
('coffee grounds') when less severe.
Melena is the term used to describe the passage of black, tarry stools containing altered blood; this is usually due to
bleeding from the upper gastrointestinal tract, although hemorrhage from the right side of the colon is occasionally
responsible.
Hematochezia is defined as the passage of red blood in the stools. Hematochezia usually represents a lower
gastrointestinal source of bleeding, although an upper gastrointestinal lesion may bleed so briskly that blood does not
remain in the bowel long enough for melena to develop. it is associated with hemodynamic instability and dropping
hemoglobin.
HOW CAN YOU CLINICALLY DIFFERENTIATE UPPER FROM LOWER

GASTROINTESTINAL BLEEDING?
Hematemesis is indicative of upper gastrointestinal bleeding.
Melena is mostly indicative of upper gastrointestinal bleeding.
Hematochezia is mostly indicative of lower gastrointestinal bleeding.
Hyperactive bowel sounds is indicative of upper gastrointestinal bleeding.
Elevated blood urea nitrogen level (due to volume depletion and blood proteins
absorbed in the small intestine) is indicative of upper gastrointestinal bleeding.
Causes of upper gastrointestinal bleeding:
Esophagitis
Esophageal varices
Mallory – Weiss tear
Esophageal or gastric tumor
Gastric erosion
Peptic ulcer
Vascular malformation
Aorto-duodenal fistula
Causes of lower gastrointestinal bleeding:
Severe/acute Moderate:
Diverticular disease
Angiodysplasia
Ischemia
Meckel's diverticulum
chronic/subacute:
Anal disease e.g. fissure or hemorrhoids
Large polyps
Inflammatory bowel disease
Solitary rectal ulcer
Carcinoma
Angiodysplasia
Radiation enteritis
Hematemesis
Ask about:
1. Hematemesis or hemoptysis?
Hemoptysis
Hematemesis
-Cough precedes hemorrhage.
-Nausea and vomiting precedes hematemesis.
-Bloody frothy from admixture with air Sputum bright red in color.
-Generally airless. -Blood often altered in color
-History suggests respiratory disease. by admixture with gastric acid and pepsin,
usually dark red or brown (coffee ground).
-Previous history of indigestion
2. Onset:
3. Duration:
4. Frequency:
5. Amount:
6. Color:
bright red blood indicate sever and recent bleeding
dark brown coffee ground-stained fluid indicate old blood degraded by gastric pepsin
7. Precipitating and the aggravating factors: alcohol, corticosteroid or NSAID therapy, trauma?
8. Relieving factors: drugs?
-Upper abdominal pain (hunger and nocturnal) as in peptic ulcer disease
-Repeated forceful vomiting which preceded haematemesis as in Mallory- Weiss syndrome
-Previous Jaundice (hepatitis) complicated to liver cirrhosis, suggestive of bleeding esophageal varices
Anorexia and weight loss: gastric carcinoma
-Other sites of bleeding: melena, bleeding from rectum, epistaxsis, gum bleeding, bruise, hematuria, menorrhagia
10. Severity: amount, frequency, clot, sign &symptoms of volume depletion and anemia
Melena
Ask about:
1. Melena or Hematochezia(rectal bleeding):
Fresh bleeding per rectum indicates hematochezia and in the absence of hemodynamic instability the likely source of bleeding is
lower gastrointestinal region
while black tarry stools indicates melena and the likely source of bleeding is upper gastrointestinal region
2. Onset:
3. Duration:
4. Frequency:
5. Character: colour, amount, consistency, odour …

(black tarry sticky offensive shiny stool)
6. Precipitating and the aggravating factors: alcohol, corticosteroid or NSAID therapy?
7. Relieving factors: drugs?
-Upper abdominal pain (hunger and nocturnal) as in peptic ulcer disease
-Repeated forceful vomiting which preceded haematemesis as in Mallory- Weiss syndrome
-Previous Jaundice (hepatitis) complicated to liver cirrhosis, suggestive of bleeding esophageal varices
-Anorexia and weight loss: gastric carcinoma
-Other sites of bleeding: melena, bleeding from rectum, epistaxsis, gum bleeding, bruise, hematuria, menorrhagia
Example1 The condition started abruptly as vomiting up of fresh blood. The patient developed initially intense retching several times
before he had vomited three times this morning but the blood was only apparent in the third vomitus and comprised about half cupful in
amount. The condition was associated with sweating and faintness. Of note the patient had no prior history of liver disease or peptic
diseases The diagnosis is upper gastrointestinal bleeding due to Mallory Weiss syndrome
Example2 The condition started abruptly this morning as vomiting up of fresh blood. The patient had vomited three times; each
comprising about one cupful of blood that was apparent in the first one and was associated with sweating, extreme weakness, and
faintness. Of note the patient had a history of liver disease and one week history of passage of black tarry stools
The diagnosis is upper gastrointestinal bleeding due to esophageal varices
Rectal bleeding
Ask about:
1. Onset:
2. Duration:
3. Frequency:
4. Character: colour, amount, consistency, clot, few drops …
5. Fresh blood? or Mixed with stool or mucous? After passage of stool? Before?
-Fresh rectal bleeding (haematochasia) indicates lesion in anal canal, rectum or colon.
-If blood is mixed with stool or coats the surface of normal stool or followed the passage of normal stool or may be seen on toilet paper
after wiping, is suggestive of ano-rectal lesion
6. Precipitating and the aggravating factors:
7. Relieving factors:
-abdominal pain and weight loss is suggestive of colorectal carcinoma -
acute sudden left sided abdominal pain is suggestive of ischemic colitis ( especially if there is an associated irregular
pulse)
-If more than one member of the family has similar history of bleeding, this would suggest hereditary polyposis syndrome
-Other sites of bleeding: melena, epistaxsis, gum bleeding, bruise, hematuria, menorrhagia
N.B. In severe upper GIT bleeding from portal hypertension a fresh rectal bleeding . from anorectal varices may occur.
N.B. Occasionally in severe upper gastrointestinal bleeding, blood may be passed unaltered causing fresh rectal bleeding
(hematochasia).
Jaundice
Ask about:
1. Site: skin, sclera, palm and sole ?
Jaundice:yellowish discoloration of the skin, sclera and mucous membrane due to hyperbilrubinaemia.
Carotenoderma (hypercarotemia): is the yellow color imparted to the skin by the presence of carotene; it occurs in healthy individuals
who ingest excessive amounts of vegetables and fruits that contain carotene, such as carrots, leafy vegetables, squash, peaches, and
oranges. Unlike jaundice, where the yellow coloration of the skin is uniformly distributed over the body, in carotenoderma the pigment is
concentrated on the palms, soles, forehead, and nasolabial folds.
Carotenoderma can be distinguished from jaundice by the sparing of the sclera.
2. Onset: acute(hemolysis, stone common bile duct) or gradual(infective, drug induced etc.)
3. Duration:
4. Course: progressive, continuous, intermittent ?
5. Precipitating and the aggravating factors:

-history of operation e.g. blood transfusion, tattoo, tooth extraction, sexual contact (Hepatitis B or C)
-sick contact (Hepatitis A or E)
-family history of hemolytic anemia (congenital spherocytosis) or liver diseases (Wilson disease, hemochromatosis and α1
antitrypsin deficiency)
-history of hemolytic anemia (G6PD deficiency, sickle cell anemia, or congenital spherocytosis), drugs (icterogenic drugs)
and alcohol, travel (Hepatitis A),
-and medical illnesses e.g. diabetes mellitus, obesity
6. Relieving factors: Treatment of acute liver disease may simply include avoidance of the precipitating agents, provision
of drugs in selected cases. In chronic liver disease this may include aspiration of abdominal ascites, shunt procedure, endoscopic
banding for esophageal varices up to and reaching to transplantation
Color of stool and urine: tea colored urine with clay color stool as in cholestatic jaundice
pallor: hemolytic jaundice
pruritus, Itching: occurs with acute liver disease, appearing early in obstructive jaundice
(from biliary obstruction) and somewhat later in hepatocellular disease (acute hepatitis). Itching also occurs in chronic liver diseases,
typically the cholestatic forms such as primary biliary cirrhosis and sclerosing cholangitis where it is often the presenting symptom,
occurring before the onset of jaundice. However, itching can occur in any liver disease, particularly once cirrhosis is present
Previous dyspepsia or biliary colic: as in cholilithiasis
Fever or rigor: suggestive of ascending cholangitis or liver abscess.
Hematemesis and melaena: as in decompensated liver cirrhosis.
Progressive failure of health and weight loss: suggest underlying malignancy(hepatoma).
any loss of appetite? Taste abnormalities (hypogeusia and dysgeusia): are recognized complications of liver disease. Smokers
with acute hepatitis B and perhaps other acute liver diseases may lose interest in cigarettes because of a perverted sense of taste from
liver inflammation. Impaired gustatory function with decreased sensitivity to bitter, salt, sweet, and sour taste has been reported in
patients with cirrhosis.
non-specific fatigue: (symptoms of chronic liver disease)
8. Severity:
N.B. Charcot's triad is the combination of fever and rigors, right hypochondrial pain, and jaundice. Reynold's pentad includes shock and
mental exhaustion in addition to Charcot's triad.
N.B. Remember that some forms of hepatocellular jaundice e.g. viral hepatitis, autoimmune hepatitis can result in cholestatic picture
because of swelling of cells and edema resulting from the disease itself that may cause obstruction of the biliary canaliculi inside the liver
(intra-hepatic cholestasis).
Causes and clinical features of pre hepatic jaundice

Causes of jaundice Clinical features
Hemolysis No stigmata of chronic liver disease other than jaundice
Normal colored urine (if the cause is extravascular
hemolysis) Normal colored stools
Pallor due to anemia
Splenomegaly due to increase reticuloendothelial activity
Gilberts syndrome (autosomal dominant) No stigmata of chronic liver disease other than mild
jaundice Normal colored urine
Normal colored stools
No pallor or splenomegaly
Causes and clinical features of hepatocellular jaundice

Viral hepatitis Jaundice
Dark colored urine
Autoimmune hepatitis
Normal colored stools
Hemochromatosis There may be stigmata of chronic liver diseases
Wilson disease
Alpha – 1 Antitrypsin deficiency
Drugs and alcohol
Causes and clinical features of cholestatic jaundice
INTRAHEPATIC CHOLESTASIS Due to cholestasis

Early features Late features
Primary biliary cirrhosis Pregnancy Jaundice Xanthelasma and
Primary sclerosing cholangitis Idiopathic recurrent cholestasis Alcohol xanthoma Pale stools
Autoimmune hepatitis Malabsorption that results in: Dark
Drugs Sever bacterial infections urine Weight loss
Viral hepatitis Post – operative Pruritus Steatorrhoea
Hodgkin's lymphoma Cystic fibrosis
Osteomalacia
Bleeding
tendency
EXTRAHEPATIC CHOLESTASIS Due to cholangitis (Charcot's triad)

Fever and rigors
Carcinoma of ampulla, pancreas, Choledocholithiasis and
bile duct, and secondary Parasitic infection Right hypochondrial pain Jaundice
metastatic depositions Traumatic biliary strictures
The likely diagnosis in patients with jaundice ''plus''

Clinical setting The likely diagnosis
Jaundice and pneumonia Mycoplasma pneumonae
Jaundice and pharyngitis Viral hepatitis
Jaundice and parkinsonian features Wilson's disease
Jaundice and hirsutism and acne Autoimmune hepatitis
Jaundice and enlarged caudate lobe Budd-Chiari syndrome
Jaundice, diabetes mellitus, and bronze skin Hemochromatosis
Jaundice and diabetes mellitus Hemochromatosis, nonalcoholic steatohepatitis, autoimmune hepatitis
Jaundice and emphysema Alpha 1 Antitrypsin deficiency
Example1 The condition started yesterday as a yellowish discoloration of the sclerae. The patient's family had repeatedly noticed
that the patient's eye discolored yellow when fasting or emotionally upset. The patient had noticed repeated attacks and in each there
was normal color of urine and stools. The patient had experienced no itching, no fever, no abdominal pain, and normal appetite. Prior to
the attack there was no drug or alcohol intake, no sick or sexual contact, and no prior operation The diagnosis is Gilbert syndrome
Example2 The condition started yesterday as a yellowish discoloration of the sclerae. The patient's family had noticed that the
patient's eye discolored yellow after two days of generalised weakness and abdominal pain. The patient had noticed repeated attacks of
altered eye color when he ingested fava beans and in each there was dark color of urine but normal stools color. The patient had
experienced no itching, no fever, and normal appetite. Prior to the attack there was no drug or alcohol intake, no sick or sexual contact,
and no prior operation. The diagnosis is G6PD deficiency. Dark colored urine owing to intravascular hemolysis.
Example3 The condition started as a yellowish discoloration of the skin and sclerae. The patient had noticed that he developed
some sort of after noon weakness, nausea, headache, and muscle pain over the preceding two months. He developed one day after that
yellowish discoloration of the skin and eyes and noticed dark color of urine but normal stools color. The patient had experienced mild
itching especially at evening, low grade fever, and reduction in appetite. Prior to the attack there was no drug or alcohol intake, no sick
contact, and no prior operation. Of note the patient had engaged in a non protected sexual contact six months ago.
The diagnosis is probably hepatitis B.
Example4 The condition started over the preceding one month as a yellowish discoloration of the skin and sclerae. He had noticed
dark color of urine and pale stools. The patient had experienced generalised itching mostly at evening, no fever, and mild reduction in
appetite. Prior to the attack there was no drug or alcohol intake, no sick or sexual contact, and no prior operation. The patient had noticed
that he developed after noon fatigue, nausea, headache, and muscle pain over the preceding one month. The diagnosis is cholestatic
jaundice e.g. primary biliary cirrhosis.
Abdominal distention
Ask about:
1.Site: all abdomen, localized, other site( periorbital, sacral, leg)
2. Onset:
Abdominal girth slowly increasing over months or years is usually due to obesity, but in a patient with weight loss it
suggests intra-abdominal disease. More rapid abdominal distension may occur in patients with intestinal obstruction due to
gaseous distention or in patients with Budd-Chiari syndrome.
3. Duration:
4. Course: progressive, continuous, intermittent ?
5. Timing:
Functional bloating is fluctuating abdominal distension that develops during the day and resolves overnight. It is
particularly common in women and is rarely due to organic disease.
6. Precipitating and aggravating factors: emotional stress, certain food?

Certain food articles such as legumes may produce gaseous abdominal distension.
7. Relieving factors: belching, vomiting or defecation?

Recurrent abdominal distension that is characteristically relieved with defecation occurs in patients with irritable bowel syndrome
8. Associated symptoms: weight gain, fever, jaundice, or vomiting?

orthopnea, and tachypnea from elevation of the diaphragm.
9. Severity: interferes with the patient's usual daily activities e.g. eating, walking, talking, and sleeping.
Factor Consider
Fat Obesity
Flatus Pseudo-obstruction, obstruction
Feces Subacute obstruction, constipation
Fluid Ascites, tumours (especially ovarian), distended bladder
Fibroid Tumours
Fetus Check date of the last menstrual period
Functional Bloating often associated with irritable bowel syndrome
Example1 The condition started gradually as progressive painless abdominal distension. The patient had noticed progressive
increase in clothing size, pulling sensation in the flank, and mild low back pain over the preceding two weeks. This distension was not
altered or relieved with belching or defecation The patient had no similar attacks previously but he was a known case of liver disease. In
the last days of his illness course he had developed a sense of breathlessness The diagnosis is ascites
Example2 The condition started over the preceding one week as progressive abdominal swelling without swelling in the other parts
of the body. The patient had noticed progressive increase in clothing size, pulling sensation in the flank, and abdominal pain together with
yellowish discoloration of the sclerae. This distension was not altered or relieved with belching or defecation. The patient had no similar
attacks previously but she is currently on chemotherapy for blood disease The diagnosis is probably Budd-Chiari syndrome
.
Genito urinary system
Loin pain or Suprapubic pain
Ask about:
1. Site: loin, suprapubic, unilateral, bilateral?
2. Onset: sudden? Gradual ?
3. duration : short? Long?
4. Character: dull ache, colicky?

Chronic dull ache pain in the renal angle occurs in chronic infection and scarring due to vesicouretric reflux or polycystic kidney
disease and chronic urinary tract obstruction
Renal (Ureteric) colic: Is caused by acute distension of renal pelvis or ureter from the passage of a stone, blood clot and renal
papilla in papillary necrosis. It is usually a sudden severe and sustained pain starting in renal angle and radiating round into the groin and
in the penis and scrotum in the male and the labia in the female associated with nausea and vomiting
5. Severity: interfere with daily activity? Sleeping? Shouting?
6. Radiation: yes or not? Where? from loin to groin?
7. Timing , progression , frequency: constant? Come in attack?

constant dull ache pain in the loin associated with fever and rigors which suggests acute pyelonephritis
sudden severe and sustained pain starting in renal angle and radiates round into the groin as in ureteric colic
8. Aggravating and relieving factors: position, drugs…
9. Associated symptoms: GUT, GIT, fever, N&V

- haematuria as seen from passage of stone
- dysuria, frequency, urgency, incontinence or hesitancy which suggests lower urinary tract infection or prostatic
hypertrophy
- polyuria, nocturia, oliguria, anuria
- fever , rigors, nausea, vomiting as in pyelonephritis
Hematuria (red color urine)
Ask about:
1. Its true hematuria or not:
- Haematuria: Presence of red blood cells in the urine due to bleeding from kidneys or urinary tract. It might be overt with bloody urine
(macroscopic) or microscopic ( detected on urine analysis) .
- contamination of the urine by blood from the female genital tract during menstruation
- other causes of red colored urine: (Hemoglobinuria, Myoglobinuria, Alkaptonuria, Bilirubinuria e.g. obstructive jaundice, Food dyes e.g.
beetroot, Drugs (phenolphthalein, senna, rifampicin, and levodopa), Porphyria)
2. Onset:
3. Duration:
4. Painful or painless:
Painless macroscopic haematuria may be due to: -Benign bladder papilloma, Cancer of kidneys or bladder and prostate,
Glornerulonephritis, Polycystic kidneys, Chronic renal infection e.g. TB, schistosomiasis.
Macroscopic haematuria with loin pain suggests renal or ureteric origin due to stone, IgA nephropathy, and acute bleeding in
polycystic kidney
5. Course: Is it initial, terminal or total?

Schistosomiasis can cause terminal hematuria
at the start of voiding and clears rapidly during micturation originated from the urethra.
6. Precipitating and aggravating factors: Trauma, catheter, stone, UTI, food, drugs.
8. Associated symptoms: (GUT, bleeding from other site, constitutional symptoms, anemia symptoms.)
- Haematuria with dysuria or frequency are due to lower urinary tract infection, cystitis or urethritis. Systemic illness e.g. bleeding
tendency, renal stone former, or hypertension.
- Fever, weight loss, night sweat:
9. Severity: clot, amount, S&S of anemia
Example1 The condition started three weeks ago when the patient had noticed passage of blood with urine Urination was not
painful and totally discolored red. The condition was associated with weight loss intermittent low-grade fever, and abdominal pain. The
patient had no prior such an attack, no medical illness, and on no any medication
The diagnosis is painless hematuria e.g. renal cell carcinoma
.
Nervous system
Headache & Facial pain
Ask about:
1. Site: unilateral, bilateral, generalized, occipital, temporal, around eyes, facial

- unilateral as temporal location of temporal arteries, cluster headache and the majority of migraine attacks.
- Ocular or retroocular pain suggests a primary ophthalmologic disorder, migraine or cluster headache
- occipital as posterior fossa lesion which causes occipitocervical pain, pain of subarchanoid hemorrhage is also occipital
- generalized headache is seen in tension headache.
- Paranasal pain localized to one or several of the sinuses, often associated with tenderness in the overlying periosteum and skin,
occurs with acute infection (acute sinusitis
- Pain within the first division of the trigeminal nerve is a common feature of post – herpetic neuralgia
- Lancinating pain localized to the second or third division of the trigeminal nerve suggests trigeminal neuralgia (tic douloureux).
2. Onset:
Causes of headache and facial pain according to the onset
Acute onset Subacute onset Chronic onset
Meningitis or encephalitis Giant cell (temporal) arteritis Migraine

Subarachnoid hemorrhage Intracranial mass Cluster headache
Other cerebrovascular diseases Pseudotumor cerebri Tension headache
Ocular disorders (glaucoma, acute iritis) Trigeminal neuralgia Cervical spine disease
Seizures Posttherpetic neuralgia Sinusitis and dental disease
3. Duration:
Migraine headaches are episodic and may last 4 – 72 hours.
tension headache may continue for weeks or months without interruption.
Cluster headache is characteristically brief and lasting 30-90 minutes
4. Character:
throbbing or pulsating as in temporal arteritis.
Tight, band like pressure (pressure over the head) as in tension headache.
focal burning sharp lancinating pain suggests a neuritic cause such as trigeminal neuralgia
5. Preceded by: (visual aura of migraine) visual disturbance(colored lines often flushing (scintillating) with scotoma. or nausea, vomiting
or photophobia associated with migraine with or without aura.
common migraine: Migraine without aura account for 80%.
classic migraine: Migraine with aura account for 20%.
6. Radiation:
Tension headache may arise from the occipital region to involve the whole areas in the head
Cluster headache occasionally spread to epsilateral side of the face or neck.
7. Time of occurrence: on awakening, during the day, end of day, night?

Morning headache or headache that awakens the patient from sleep may indicate raised intracranial pressure.
At end of day a in tension headache.

nocturnal awakening the patient 2-3 hours after the onset of sleep as in Cluster headache
8. Course & progression:

Periodic non progressive headache is seen in migraine.
Constant and progressive suggest the presence of structural brain lesions.
Fluctuations in intensity and duration of the headache with no obvious cause especially when associated with similar fluctuations in
mental status, are seen with subdural hematoma
9. Severity:
whether or not the headache interferes with sleeping, eating, talking, walking, or other usual daily activities.
N.B. (the worst headache in my life! as described by the patient) suggests subarchanoid hemorrhage.
10. Precipitating and aggravating factors:

stress in tension headache.
cheese, chocolate or red wine. oral contraceptive agents or nitrates may precipitate migraine.
alcohol is typical of cluster headache
light touching of the face, brushing of the teeth and shaving as in trigeminal neuralgia.
eating ( swallowing) as in glossopharyngeal neuralgia.
rapid changes in head position as in coughing and sneezing often associated with an intracranial mass but can occur in migraine
Anger, excitement, or irritation can precipitate or worsen migraine and tension headaches.
Stooping, bending forward, sneezing, or blowing the nose characteristically worsens the pain of sinusitis.
Postural headache (maximal when upright, nearly absent when lying down) occurs with low cerebrospinal fluid (CSF) pressure caused by
lumbar puncture, head injury, or spontaneous spinal fluid leak

darkness, sleep, vomiting, or pressing on the ipsilateral temporal artery, and their frequency is often diminished during pregnancy in
migraine.
Recumbency as in Postlumbarpuncture and low-pressure headaches.
Drugs:

fever, neck stiffness as in meningitis together with profound alteration in level of consciousness as in encephalitis or meningoencephalitis.
Recent weight loss may accompany cancer or giant cell arteritis.
Visual disturbances suggest an ocular disorder, migraine, or an intracranial process involving the optic nerve or tract or the central visual pathways
Photophobia phonophobia osmophobia, N&V in migraine
Ptosis, myosis, congested eye and nose in cluster headache’
N.B. Acute, severe headache with stiff neck and fever suggests meningitis.
Acute, severe headache with stiff neck but without fever suggests subarachnoid hemorrhage.
N.B. Headache of raised intracranial pressure

Dull ache, often mild Relieved by analgesia, Associated with morning vomiting, Worse in morning, improves through the day, Worse
bending forward, Worse with cough and straining
N.B. Most migraine aura symptoms develop over 5 to 20 minutes and usually last less than 60 minutes. The aura can be characterized
by visual, sensory, or motor phenomena. Headache, when present, usually occurs within 60 minutes of the end of the aura. The most
frequently occurring aura is visual in nature e.g. scotomata, simple flashes, shimmering of light or silvery zigzag lines. Paresthesias are
the second most common aura: a spreading front of tingling followed by numbness which moves, over 20-30 minutes, from one part of
the body to another.
Example1 The condition started almost every day for the preceding three years as headache that initially localised to the back of
the head then became generalized to involve the whole head, mild in intensity and band- like in nature, although at certain occasions
became throbbing. The patient experienced headache almost every day particularly in the evening and became less noticeable in the
morning This headache was not associated with nausea or vomiting, or visual disturbance apart from very infrequent occasion of muscle
ache, exacerbated during stress and relieved when the patient was busy or went to bed. The diagnosis is tension headache
Example2 The condition started as visual disturbance in the form of zigzag lines marching across the right eye over 20 minutes
then she developed headache one hour after the end of the initial visual complain. She experienced headache once monthly for the
the head and face, mild in intensity at the start then became of moderate severity, previous three years that was localised the right side of
and pulsating in nature. The headache precipitated with ingestion of chocolate and persisted for 24 hours. During this time, the patient
had nausea and vomiting and preferred to sleep and stay in dark environment. The patient had an exacerbation during menses and slight
improvement when became pregnant or developed vomiting The diagnosis is migraine headache
Example3 The condition started as headache and right eye pain that were awaken him from sleep in the early hours of the day and
exactly recurred in the same time each day for around 4 weeks before it disappeared but after 3 months the headache and facial pain
recurred again. The headache was localised to the right side of the head and face, moderately severe in intensity, dull in nature, and
relieved with oxygen therapy. The headache precipitated by alcohol intake and lasted for 30 minutes only. During this time, the patient
had right nasal congestion and right eye tearing The diagnosis is cluster headache
Example4 The condition started every day in the morning for the preceding ten days as headache that was involving the whole
front and back of the head. The headache was mild in intensity, dull ache in character, associated with early morning vomiting and visual
disturbance, and slightly improved through out the day. The headache was exacerbated with cough, straining, and bending forward and
improved pain medication The diagnosis is headache of raised intracranial pressure
.
Seizure
Classification and causes of seizure

CLASSIFICATION OF SEIZURE
Focal (partial) seizure Generalized seizure
Simple partial seizure Tonic clonic (grand mal epilepsy)
Complex partial seizure Tonic seizure
Partial seizure with secondary generalization Clonic seizure
Atonic seizure
Myoclonic seizure
Absence seizure (petit mal epilepsy)
CAUSES OF SEIZURES
Idiopathic Some types of the benign epilepsies of the childhood
Genetic Tuberous sclerosis, neurofibromatosis, and von Hippel-Lindau disease
Developmental Hydrocephalus
Tumours Primary and secondary brain tumors
Trauma Including surgery
Vascular Cerebrovascular accident (CVA)
Infections Meningitis, encephalitis, cerebral abscess, and toxoplasmosis
Inflammation Vasculitis (SLE) and multiple sclerosis (uncommon)
Metabolic Hypocalcemia, hyponatremia, hypomagnesemia, and hypoglycemia
Renal failure and liver failure
Drugs, alcohol and toxins Antibiotics: penicillin, isoniazid, metronidazole
Psychotropic agents: phenothiazines, tricyclic antidepressants, lithium
Degenerative Alzheimer's disease (uncommonly)
A seizure is a paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of central nervous
system (CNS) neurons that may be manifested as an impairment or loss of consciousness, abnormal motor activity, sensory disturbance,
autonomic dysfunction as well as behavioral abnormalities
Epilepsy describes a condition in which a person has recurrent seizures due to a chronic underlying process.
What is meant by aura? The aura is the portion of the seizure that precedes loss of consciousness in complex partial seizure and
partial seizure with secondary generalization and of which the patient retains some memory. It is reserved for subjective internal
symptoms of epileptic origin reported by the patient in the absence of objective signs. The aura is sometimes the sole manifestation of the
epileptic discharge.
N.B. you need to read and understand about each type of seizure
Ask about:
1. First attack or recurrent?
2. Affect one part of the body or generalized?

The clonic or tonic movement involves one part of the body as in simple partial seizures or generalized from the outsets as
in grand mal convulsion
3. Consciousness (not affected, impaired, lost abruptly)

lost abruptly as in grand mal convulsion
consciousness retained as in simple partial seizures
consciousness is impaired as in complex partial seizures
4. Fit last for how long? And followed by post ictal period (lethargy, weakness, amnesia)
5. To reach the type ask:

grand mal convulsion:
The clonic or tonic movement involves all the body from the start.
The attack accompanied by a loud epileptic cry (ictal cry or moan)
The attack is associated with incontinence, tongue biting and cyanosis.
The attack is followed by confused and amnesic state.
simple partial seizures:
The clonic or tonic movement involves one part of the body.
The attack is followed by focal weakness or numbness (Todd's paralysis) as in simple partial seizure.
Simple partial seizures may evolved into complex partial seizures in which consciousness is impaired.80%
temporal lobe epilepsy: The attack is preceded by hallucination of smell, taste, or auditory, disturbance of memory, abnormal behaviour.
Absence seizure (petit mal epilepsy): The attack is characterized by sudden momentary lapses in awareness without loss of
consciousness with immediate recovery.
Atonic seizures (drop attacks): Occurs most often in children characterized by sudden loss of muscle tone that may result in falls
sometime with self injury.
Myoclonic seizures: characterized by rapid recurrent, brief muscle jerks that can occur bilaterally, synchronously, asynchronously or
unilaterally without loss of consciousness. Repeated myoclonic seizures may seem to terminate into a generalized tonic clonic
convulsion. Seizures usually occur shortly after waking or while falling sleep.
6. Review of CNS:
7. Drugs: tricyclic antidepressant and INH

Example1 The condition started suddenly as jerking movement involving the right side of the body whilst the patient was standing
washing his face made him fallen to the ground. The patient developed jerking movement in the form of periodic relaxation and
contraction of that part of the body lasting five minutes before the attacks is abolished spontaneously. During this attack the patient had
not lost his consciousness, not urinate upon himself, and there was no tongue biting. After the attack the patient was just terrible from
these events but fully conscious, able to respond to environment and asked for help as he had slight weakness involving the right upper
and lower limbs. No drugs or alcohol had been taken prior to this attack The diagnosis is simple partial motor seizure of clonic type
Example2 The condition started whilst the patient was standing washing his face as stiffening and rigidity involving the right arm
and the right leg made the patient fallen to the ground. The attack lasted five minutes and then abolished spontaneously. During this
attack the patient had not lost his consciousness, not urinate upon himself, and there was no tongue biting. After the attack the patient
was just terrible from these events but fully conscious, able to respond to environment and asked for help as he had slight weakness
involving the right upper and lower limbs. No drugs or alcohol had been taken prior to this attack
The diagnosis is simple partial motor seizure of tonic type
Example3 The condition started suddenly whilst the patient was standing washing his face as instantaneous electric sensation
involving the right arm and the right leg that was so unpleasant and lasting two minutes before the attacks is abolished spontaneously.
During this attack the patient had not lost his consciousness, not urinate upon himself, and there was no tongue biting. After the attack
the patient was just terrible from these events but fully conscious, able to respond to environment and asked for help. No drugs or alcohol
had been taken prior to this attack The diagnosis is simple partial sensory seizure
Example4 The condition started suddenly whilst the patient was sitting as abnormal sensation though to arise from the patient's
abdomen that lasted for about 20 seconds before the patient lost his consciousness as the witness repeatedly called him with no
response. The witness then had stated that the patient become motionless stare and stopped speech and movement for a while before
he started to have repeated picking movements of his hands lasted for two minutes. During this attack the patient had not urinated upon
himself and there was no tongue biting. After the attack the patient regained his consciousness gradually, feeling so terrible from these
events and mild weakness involving the whole body. No drugs or alcohol had been taken prior to this attack
The diagnosis is complex partial seizure
Example5 The condition started suddenly whilst the patient was sitting as abnormal sensation though to arise from the patient's
abdomen that lasted for about 20 seconds before the patient fallen to the ground lost his consciousness as the witness repeatedly called
him with no response. The witness then had stated that the patient whole body became very stiff and rigid for 30 seconds. During this
part, the patient lost his consciousness, his respiration is arrested, his tongue was severely injured, and he became markedly blue. Then
he developed jerking movement with periodic relaxation and contraction involving the whole body parts for further 30 seconds; the jerking
movement became less noticeable with the time until he became flaccid. After the attack the patient was urinated upon himself and his
mouth was full with secretion. The patient stayed with disturbed consciousness for 30 minutes before he regained his consciousness so
slowly, feeling so terrible from these events and weakness involving the whole body. No drugs or alcohol had been taken prior to this
attack The diagnosis is secondary generalised tonic – clonic seizure
Example6 The condition started suddenly whilst the patient was sitting as sudden fall onto the ground with loss of consciousness
as the witness repeatedly called him with no response. The witness then had stated that the patient whole body became very stiff and
rigid for 30 seconds. During this part, the patient lost his consciousness, his respiration is arrested, his tongue was severely injured, and
he became markedly blue. Then he developed jerking movement with periodic relaxation and contraction involving the whole body parts
for further 30 seconds; the jerking movement became less noticeable with the time until he became flaccid. After the attack the patient
was urinated upon himself and his mouth was full with secretion. The patient stayed with disturbed consciousness for 30 minutes before
he regained his consciousness so slowly, feeling so terrible from these events and weakness involving the whole body. No drugs or
alcohol had been taken prior to this attack The diagnosis is primary generalised tonic – clonic seizure
Example7 The condition started suddenly whilst the patient was standing washing his face as stiffening and rigidity involving the
whole body parts made the patient collapsed and fallen to the ground. During the attack which last one minute, the patient lost his
consciousness, his respiration is arrested, he became markedly blue, and his tongue is severely bitten. He did not develop jerking
movement with periodic relaxation and contraction after that. The patient after that had urinated upon himself, was so terrible from these
events, unable to respond to environment, and felt headache and would like to sleep. No drugs or alcohol had been taken prior to this
attack The diagnosis is primary generalised tonic seizure
Example8 The condition started suddenly whilst the patient was standing washing his face as jerking movement with periodic
relaxation and contraction involving the whole body parts made the patient collapsed and fallen to the ground. During the attack which
last one minute, the patient lost his consciousness; the jerking became less noticeable with the time till the patient became flaccid. The
patient after that had urinated upon himself, was so terrible from these events, unable to respond to environment, and felt headache and
would like to sleep. No drugs or alcohol had been taken prior to this attack The diagnosis is primary generalised clonic seizure
Limb or muscle weakness
Ask about:
1. Onset:
abrupt onset suggests a vascular disturbance such as a stroke, or certain toxic or metabolic disturbances.
subacute onset of days to weeks is commonly associated with a neoplastic, infective, or inflammatory process.
chronic evolves slowly over several months or years often has a hereditary, degenerative, endocrinologic, or neoplastic basis.
2. Duration:
3. Course:
intermittent weakness include myasthenia gravis, periodic paralyses (hypokalemic, hyperkalemic, and paramyotonia congenita), and
metabolic energy deficiencies.
persistent muscle weakness include most types of muscular dystrophy, polymyositis, and dermatomyositis.
4. Timing: Myasthenia gravis characteristically has diurnal variation with the patients being well in the morning and worsen at the
end of the day
5. Site: proximal, distal, generalized or localized, one limb or two limbs on the same side or both lower limbs or four limbs, specific muscle group?
if proximal ask: Climbing stairs? Stand from chair? Lifting object? Wash hair
If distal ask: tripling? Poor hand grip(turn door knop)?
proximal weakness: like in dermatomyositis, polymyositis, thyrotoxicosis or secondary to corticosteroids therapy.

distal weakness: as in seen in peripheral neuropathy or neuromuscular disorders as in peroneal muscular atrophy.
6. Progression:
starts distally and ascends proximally to involve the upper limbs and respiratory muscles as in Guillain-Barre-syndrome.
starts distally and descend proximally As in botulism.

- The weakness of myasthenia gravis is characteristically worsened by repeated exertion (fatigability) and improved by rest.
- exercise and cold may precipitate weakness in paramyotonia congenital.
- carbohydrate meal ingestion may precipitate hypokalemic periodic Paralysis.
- potassium ingestion may precipitate hyperkalemic periodic paralysis.
- predisposing factors for cerebrovascular disease: Any associated disease, like diabetes mellitus.bypertension or if the patient is aware
of having valvular heart disease or myocardial disease or having hyperlipidemia.
- The patients mobility whether immobile or bedfast? (disuse atrophy)
The weakness of myasthenia gravis is characteristically and typically improved with rest
The weakness of Lambert Eaton syndrome is improved with exercise
9. Associated symptoms: CNS, locomotor system

fasciculation as in motor neuron disease.
Dysarthria, dysphasia as in cerebrovascular disease.
sensory loss may suggest neuropathic cause of weakness
10. Severity:
Family history: as in hereditary muscular dystrophy.
Drug history: like corticosteroids causing proximal myopathy.

Causes of muscle weakness

Endocine Metabolic
Hypothyroidism Cushing's syndrome
Hypokalaemia
Hyperthyroidism Addison's disease
Glycogen storage diseases
Osteomalacia Diabetes mellitus
Drugs/toxins Infections
Alcohol Amiodarone Viral (HIV, CMV, rubella, Epstein-Barr)
Fibrates Statins Bacterial (Clostridia, staphylococci, tuberculosis, Mycoplasma) Parasitic
Steroids ß-blockers (schistosomiasis, toxoplasmosis)
Neurological
1 Supraspinal lesions Stroke and other structural lesions
2 Spinal cord lesions
3 Anterior horn cell disorders Poliovirus
4 Peripheral neuropathy (motor)
5 Neuromuscular junction disorders Myasthenia gravis, Lambert Eaton syndrome, and botulism
Muscle disorders
1 Inflammatory Polymyositis, dermatomyositis, and inclusion body myositis
2 Muscle dystrophy
Some groups of channelopathies

Channel Muscle disease Clinical features
Sodium Paramyotonia congenita Cold-evoked myotonia with episodic weakness provoked by exercise
and cold
Hyperkalemic periodic Brief, frequent episodes of weakness triggered by potassium ingestion
paralysis
Hypokalemic periodic Episodic weakness triggered by carbohydrate meal
paralysis
N.B. The five “Ds” describe the major symptoms of botulism: (1) diplopia; (2) dysphonia; (3) dysarthria; (4) dysphagia and (5)
descending, symmetric flaccid paralysis that develops 12 to 72 hours after exposure
N.B. Patients with Lambert Eaton syndrome had antibodies to pre-junctional voltage-gated calcium channels, may have autonomic
dysfunction in addition to muscle weakness, but the cardinal clinical sign is absence of tendon reflexes, which can return immediately
after sustained contraction of the relevant muscle. The condition is associated with underlying malignancy in a high percentage of cases.
These include lung cancer, breast cancer and ovarian cancer
Example1 The condition started gradually over the preceding one month when the patient had noticed muscle pain and weakness.
The patient had noticed that she became unable to ascend stairs or to raise her body from sitting position but her hands function
normally. Her muscle weakness was persistent all of the time but got improvement with the use of a course of drugs. The patient had no
prior history of drugs intake, infection, or alcohol. Of note the patient developed skin rash around her eye, over her hands, and upper
chest The diagnosis is dermatomyositis
.
Disturbance of consciousness
Ask about:
1. Onset:
sudden onset which suggests ischemic or hemorrhagic stroke affecting the brain stem or of subarchanoid hemorrhage.
2. Duration:
3. Preceded by:
premonitory headache, fever, neck stiffness supports a diagnosis of encephalitis, meningitis or subarachnoid haemorrhage.
period of intoxication, confusion, delirium points to· diffuse process such as encephalitis, endogenous or exogenous toxins.
aphasia or hemiparesis which occurs in hemispheric mass lesion or infarction.
4. Associated symptoms: CNS

- Risk factors for cerebrovascular accidents or metabolic encephalopathy such as smoking, hypertension, diabetes mellitus, uremia or
jaundice.
- Whether the patient is aware of any valvular or other cardiac diseases.
- Any history of sickle cell disease, SLE or features of antiphospholipid syndrome.
- Any preceding epileptic seizures.
- Drug history like narcotics, hypnotics and heavy sedative drug
Disturbance of vision
Ask about:
1. Onset:
Acute transient monocular blindness is usually the result of embolization to the central retinal artery from an atheromatus plaque in the
carotid artery (Amaurosis fugax).
Gradual bilateral visual loss caused by optic nerve lesion is a feature Leber's hereditary optic neuropathy.
Acute transient bilateral visual loss may be a symptom of raised intracranial ~pressure, papilloedema is often severe.
Bilateral damage to optic radiation or visual cortex result in cortical blindness which are caused by basilar artery insufficiency,
hypertensive encephalopathy and CVA.
2. Duration:
3. Site: unilateral or bilateral?
4. Partial or complete:
5. Permanent or transient: Was there a complete recovery?
6. Course: persistent, intermittent
7. Associated symptoms: CNS

- headache, scalp tenderness and myalgia as in Ischemic optic neuropathy.
- Positive visual phenomenon such as photopsia (flashes of light); phosphones (blue lights) or scintillating scotoma is characteristic of
migrainous aura and reflects oligaemia to the occipital lobe.
N.B. Retinal artery occlusion and retinal vein occlusion can cause permanent blindness.
Vertigo
Central Peripheral
Vertebrobasilar insufficiency Ménière's disease
Brainstem or cerebellum ischemia or infarction Benign paroxysmal positional vertigo (BPPV)
Multiple sclerosis Vestibular neuronitis (acute labyrinthitis)
Migraine Drugs, e.g. gentamicin, anticonvulsants
Cerebellopontine angle tumors e.g. acoustic neuroma
Benign paroxysmal positional vertigo: is by far the most common type of vertigo. Patients with this condition suddenly develop
brief episodes of vertigo (few seconds to minutes) with position change, typically when turning over in bed getting in and out of bed,
bending over and straightening up, or extending the neck to look up. It is sometimes associated with nausea and no hearing loss, no
deafness, and no neurologic symptoms. The course of vertigo is persistent for few weeks and recurrent. It commonly occurs
spontaneously in older people.
Vestibular neuronitis (acute labyrinthitis): describes the sudden onset of vertigo, nausea, and vomiting lasting hours to days, up
to two weeks and not associated with deafness, tinnitus, or neurologic symptoms. Most affected patients gradually improve over 1 to 2
weeks although vertigo may recur over 12 – 18 months. Many report an upper respiratory tract illness 1 to 2 weeks before the onset of
vertigo.
Ménière's syndrome: is a condition associated with fluctuating hearing loss and tinnitus recurrent episodes of abrupt and often severe
vertigo lasting several hours to a day or more, a sensation of fullness or pressure in the affected ear, and nausea and vomiting.
Drugs toxicity: may cause acute or insidious onset of vertigo that may or may not be reversible, associated with nausea and vomiting,
and may be associated with hearing loss in both sides and tinnitus.
Vertigo with vertebrobasilar insufficiency is abrupt in onset, usually lasting several minutes, and is frequently associated with
nausea and vomiting
Vertigo in multiple sclerosis is usually transient and often associated with other neurologic signs of brain stem disease, in
particular, internuclear ophthalmoplegia or cerebellar dysfunction.
Vertigo is a common symptom with migraine. It can occur with headaches or in separate isolated episodes, and it can predate
the onset of headache
Vertigo of cerebellar origin is exceptional in this respect in that it may rarely be the sole manifestation of cerebellar infarction or
hemorrhage.
N.B.
The peripheral localization of vertigo is suspected when: the attack is marked, having finite duration (minutes days, weeks) but
recurrent, alone or in combination with nausea and vomiting, with or without deafness and tinnitus, and no neurologic findings.
The central localization of vertigo is suspected when: the attack is mild in severity, having protracted course rarely alone, and is
confirmed by neurologic findings of involvement of the brainstem (cranial nerves, sensory and motor tracts, etc.) or cerebellum (cerebellar
ataxia with eyes open, nystagmus, dysarthria, etc.) that accompanied the attack as well as normal hearing function (no deafness or
tinnitus).
Ask about:
1. Its real vertigo?
Vertigo: Abnormal perception of movement of the environment (an illusory sense of unidirectional rotational movement). Patient senses
that the world spinning or that he is spinning within the world. These may be associated with nausea, vomiting and impending loss of
consciousness occurs as a result of mismatch between information about a person's position reaching the brain from the eyes, limb
proprioception and vestibular system.
2. Onset:
3. Duration:
5. Precipitating and aggravating factors: change in position, drugs, trauma

Positional vertigo: described as severe vertigo induced by maneuver of moving from an upright to a recumbent posture and/or rolling
over the bed.
6. Relieving factors: sleep or medications
- The vertigo is associated with ear problem as in labyrinthitis or without as in vestibular neuritis.
- progressive unilateral hearing loss as in Meniere's disease.
- The vertigo is sudden onset associated with disequilibrium, truncal ataxia as in cerebral hemorrhage or infarction.
- The vertigo is associated with double vision, dysphagia, and dysphonia with: epsilateral facial pain as in Wallenberg's syndrome.
8. Severity:
Example1 The condition recurred on awakening in this morning as a feeling of unsteadiness and motion of the head and the
surroundings. Four previous attacks occurred during the previous two days. Each attack lasted for about 1 minute and was moderately
severe rendering the patient disliking to change his head position as it was mainly triggered by such an act. There was no associated
tinnitus, deafness, hiccups or double vision; just a sense of nausea that is followed by vomiting and headache
The diagnosis is peripheral (labyrinthine) vertigo e.g. BPPV
Example2 The condition started on awakening this morning as a feeling of unsteadiness and motion of the head and the
surroundings. The attack was mild, persisting for more than several minutes and was associated with double vision, drop attacks and
weakness, nausea and vomiting. There was no associated tinnitus or deafness. There was no prior history of drugs intake
The diagnosis is central vertigo due to vertebrobasilar insufficiency
Locomotor system
(Musculoskeletal system)
The principal clinical complaints of joint disease are joint pain, stiffness, swelling, or limitation of joint movement
Causes of arthritis are wide and include:
1. Infection: In adults the most likely organism is Staphylococcus aureus, particularly in patients with rheumatoid
arthritis and diabetes. In young, sexually active adults disseminated gonococcal infection is an important cause.
Amongst the elderly or those who misuse intravenous drugs, Gram-negative bacilli or other microorganisms are
important.
2. Seropositive arthritis: e.g. rheumatoid arthritis.
3. Seronegative arthritis: Ankylosing spondylitis, Reactive arthritis (Reiter's syndrome), Psoriatic arthropathy, Arthritis
associated with inflammatory bowel disease (Crohn's disease, ulcerative colitis).
4. Connective tissue diseases: e.g. systemic lupus erythematosus, systemic sclerosis, and Sjögren's syndrome.
5. Crystal-associated diseases: e.g. gout and pseudogout.
6. Malignancy: e.g. leukemia, lymphoma, and hypertrophic osteoarthropathy.
7. Vasculitis: e.g. polyarteritis nodosa and cryoglobulinemia.
8. Drugs: e.g. corticosteroid withdrawal, glibenclamide, methyldopa, ciclosporin, isoniazid, and barbiturates.
9. Systemic diseases:
Gastrointestinal diseases: Hemochromatosis, autoimmune hepatitis, primary biliary cirrhosis, gluten-sensitive, enteropathy,
and inflammatory bowel disease
Hematological disorders: Hemophilia, hemoglobinopathies, and plasma cell dyscrasias
Endocrine disorders: Diabetes mellitus, thyroid disorders, parathyroid disorders, and acromegaly
Other: Sarcoidosis, relapsing polychondritis, and cystic fibrosis
Joint problems (pain, stiffness, swelling)
Ask about:
1. Articular or non-articular?
Features that suggest an articular process:
Symptoms (pain) localized to the joint(s).
Physical findings (swelling, erythema, heat, or tenderness).
Joint range of motion is painful.
Joint range of motion is restricted.
2. Inflammatory or non-inflammatory?
Features that suggest an inflammatory process:
Morning stiffness longer than 60 minutes (versus worsening in the evening in mechanical processes) Gel phenomenon (stiffness after
prolonged inactivity .
Symptoms improve with use (versus worsening with use in mechanical processes).
Joint swelling, erythema, heat, or tenderness.
Active constitutional manifestations (e.g., fever, malaise, anorexia or weight loss).
3. Onset: pain in haemoarthrosis, traumatic injury and crystal induced arthritis is of abrupt onset
Duration: The duration of acute arthritis is less than 6 weeks while that of chronic arthritis is more than 6 weeks.
5. Timing:
6. Site: which joint? Peripheral or axial?

The first metatarsophalangeal joint as in gout.
small joints of the hands especially proximal interphalangeal joints or metacarpophalangeal as in rheumatoid arthritis.
distal interphalangeal joints as in osteoarthritis or psoriatic arthritis
7. Number of joint involved: Monoarthritis (one joint)? oligoarthritis ( 2-4 joints)? polyarthritis (more than 4 joints)?
Symmetry:
Symmetrical: as in rheumatoid arthritis and SLE.
asymmetrical: as in seronegative arthritis.
8. Nature of involvement:
Migratory arthritis means involvement of new joint and the previous one had been improved as in Gonococcal arthritis Mumps arthritis.
Acute rheumatic fever, Relapsing polychondritis Leukemia, Hyperlipidaemia
Additive means involvement of new joint and the previous one still involved
bloody diarrhea: as in inflammatory bowel disease
Associated extra articular features:
- Skin lesion and nail pitting as in psoriasis.
- Skin lesion aggravated by exposure to light as in SLE.
- Skin lesion like crythema marginatum as seen in acute rheumatic fever and erythema nodosum as seen in inflammatory bowel disease.
- Thick tight skin as in sclcrodenna.
- Bleeding in to the skin (bruises) or bleeding from other site as in associated leukemia.
- Subcutaneous or bony nodules as in rheumatoid arthritis or osteoarthritis.
- Red eye, conjunctivitis or scleritis as in reactive arthritis (Reiter's) or in spondyloarthropathy.
- Reduction in tear production.
- Oral ulcers as in SLE and Behcets.

- Preceding urethritis (urethral discharge) as in Behcet's syndromes and Reiter's or diarrhea (whether bloody or not) as in Reiter's
disease.
Constitutional symptoms: as fever, fatigue, weight loss as in septic arthritis and in systemic autoimmune disease, brucellosis or
inflammatory bowel disease.ether bloody or not) as in Reiter's disease
10. Precipitating and aggravating factors: activity, rest, operation, drugs, sexual contacts, or dysentery?
drugs: which might cause adverse musculoskeletal effect like corticosteroids causing myopathy or statin causing myalgia, myositis or
myopathy.
Reiter's disease or reactive arthritis typically develops 1-3 weeks following sexual exposure or an attack of dysentery.
Gouty attack may follow operation
11. Relieving factors: rest, exercise, work?
12. Severity: Severity is determined as to whether pain interferes with daily activities like sleeping, eating, etc
Causes of arthritis according to the number of joints involved

Monoarthritis Oligoarthritis Polyarthritis
Septic arthritis Osteoarthrosis (most common) Rheumatoid arthritis
Gout and pseudogout Seronegative spondarthritis Lupus
Trauma Infection as in bacterial endocarditis Systemic sclerosis
Hemarthrosis in clotting abnormality Juvenile idiopathic arthritis Polymyositis
Foreign body (e.g. plant thorn) Oligoarticular presentation of Viral arthritis
Monoarticular presentation of polyarthritis Seronegative spondarthritis
polyarthritis Chronic gout
Hemochromatosis
Acromegaly
Cause Characteristics
Rheumatoid arthritis Symmetrical, small and large joints, upper and lower limbs
Seronegative arthritis Asymmetrical, large > small joints, lower > upper limbs,
spondylitis
Lupus Symmetrical, small > large joints, joint damage uncommon
Systemic sclerosis and Symmetrical, small and large joints
polymyositis
Juvenile idiopathic arthritis Symmetrical, small and large joints, upper and lower limbs
Chronic gout Distal > proximal joints, preceded by acute attacks
Viral arthritis Very acute, self-limiting
Example1 The condition started gradually over the preceding year as mild joint pain and limitation of movement. The patient had
noticed that both knee joints had been affected simultaneously and symmetrically but no redness or hotness, and with ten minutes of
early morning stiffness. Her joints became better with rest and worse with movement. The patient had not experienced fever or weight
loss and there was no prior history of sexual contact, bloody bowel motion, drugs or alcohol intake
The diagnosis is osteoarthritis of the knee joints
Example2 The condition started gradually over the preceding three days as joint pain and limitation of movement. The patient had
noticed that the right knee joint had become red, hot, swollen, and painful, with severe limitation in its movement. Her joint became better
with rest and worse with any joint movement. The patient had experienced high grade fever with loss of appetite. Prior to the attack, there
was no prior history of joint problem, sexual contact, bloody bowel motion, drugs or alcohol intake.
The diagnosis is septic arthritis of the right knee joint
Example3 The condition started gradually over the preceding eight weeks as joint pain and limitation of movement. The patient had
noticed that her right and left wrist joints and finger joints had become hot, swollen, and painful, with severe limitation in its movement that
incapacitated her to perform her daily activities in the early morning. Her condition then deteriorated when her ankle joints had also been
involved in an additive manner. She experienced one and half hour of early morning stiffness and noticed that her joint became better
after work and with the use of pain medications and worse after rest. The patient had experienced intermittent low-grade fever, red painful
eyes with reduction of appetite. Prior to the attack, there was no prior history of joint problem, sexual contact bloody bowel motion, drugs
or alcohol intake The diagnosis is rheumatoid arthritis
Example4 The condition started gradually over the preceding three months as joint pain and limitation of movement. The patient
had noticed that his right hip and right knee joints had become hot, swollen, and painful, with severe limitation in its movement that
incapacitated her to perform her daily activities in the early morning. Her condition then deteriorated when her left ankle joint and right
elbow had also been involved in an additive manner. She experienced one and half hour of medications and worse with rest. The patient
had experienced intermittent low-grade fever with mild early morning stiffness and noticed that her joint became better after work and with
the use of pain reduction of appetite. Prior to the attack, there was no prior history of joint problem, sexual contact, bloody bowel motion,
.drugs or alcohol intake. Of note the patient had chronic history of skin disease. The diagnosis is seronegative psoriatic arthropathy
.
Skin
Skin rash
Ask about:
1. Onset:
2. Duration:
3. Course:
4. Site (distribution): for example eruption in antecubital and popliteal fossa indicates atrophic eczema while plaques 00 the
extensor surface of knee and elbow suggest psoriasis.
5. Symmetry: Symmetrical or universal eruptions usually suggest systemic or constitutional causes while asymmetrical skin
rashes suggest dermatological causes.
6. Character: shape, color, raised or flat, size…

primary or secondary skin lesion?
Itchy or not? localised pruritus is usually due to dermatological disease
Painful? Determine if pain or disturbed sensation has occurred; for example, inflammation and edema can produce pain in the skin, while
disease involving neurovascular bundles or nerves can produce anesthesia (e.g. leprosy, syphilis).
7. Precipitating and aggravating factors: drugs, heat, cold exposure, Insect bite, Trauma,
8. Relieving factors: drugs, sun, cold exposure ..
Local: itching, painful, any dropping off of scales from skin and scalp, as in psoriasis
Systemic:
Presence of any symptoms suggesting an underlying disease. Steven-Johnson's syndrome caused by mycoplasma pneumonia
fever in infectious diseases
Past history:
past medical history of asthma, eczema or hay fever suggests atopy.
diabetes mellitus, connective tissue disease, inflammatory bowel disease
Social history: needs to be obtained regarding occupation and hobbies, as chemical exposure and contact with
animals or plants can all induce dermatitis
Family history: Psoriasis and atopic eczema have strong inherited traits
Drug history: All medications that have been taken must be documented. Orally ingested or parenteral medications
can cause a whole host of cutaneous lesions and can mimic many skin diseases
Others
Fever
Ask about:
1. Onset: sudden or gradual?
2. Duration:
3. Grade:
Assessed by (touch, thermometer)?
Sweating/rigor/chills/shivering?
4. Pattern:
Continued fever is a type of fever that is fluctuating but not more than 1°C during 24 hours and never reaching the normal base – line. It
occurs in typhoid fever, drug fever, malignant hyperthermia
Remittent fever is similar to continued fever but with a daily fluctuation of more than 2 °C and temperature does not return to normal.
This type of fever is not characteristic of any particular disease
Intermittent fever is a type of fever that is present only during few hours in 24 hours i.e. temperature falls to normal each day. It occurs in
pyogenic infections, lymphomas, miliary tuberculosis
Relapsing fever is characterized by returning of temperature to normal for days before rising again. It occurs in:
Malaria: Tertian-3-day pattern, fever peaks every other day (Plasmodium vivax, P. ovale).
Quartan-4-day pattern, fever peaks every 3rd day (P. malariae)
Lymphoma: Pel-Ebstein fever (1 week with fever and 1 week without fever) of Hodgkin's disease (rare)
Pyogenic infection: Similar to intermittent fever but had wider fluctuation. It is called Hectic fever
5. Timing: more at night or day?

fever more at night and associated with sweating as in tuberculosis.
6. Progression:

Drugs that cause fever include penicillins, cephalosporins, antituberculous anticonvulsants (particularly phenytoin), and methyldopa
Consumption of unpasteurized milk (brucellosis).
8. Relieving factors: cool sponging or medications?
9. Associated symptoms: review of all systems

sweating: If there is sweating determine the time of occurrence (day or night time) and its nature whether profuse (drenching) or slight.
Chills mean just bed shaking and are encountered in most febrile illnesses. However, a teeth-chattering, bed-shaking chill indicative of a
true rigor is usually associated with bacteremia, pyelonephritis, abscess and biliary tract infection.
Malaise, headache and pain in the muscles and joints often accompany fever
arthralgia or arthritis as in sickle disease, brucellosis and hematological malignancy or connective tissue diseases.
Skin rash :
Sore throat as in pharyngitis, tonsillitis, EBV infection.
Cough, sputum, chest pain as m lower respiratory infection.
Cough, sputum, haemoptysis as m TB, bronchogenic carcinoma and bronchiectasis
Loin pain, dysuria and frequency as in pyelocystitis
Upper abdominal pain with rigor and jaundice as in biliary stones and cholangitis
Acute watery diarrhea caused by enterotoxigenic strain of E-coli or by viruses such as rotavirus
Prolonged diarrhea with profound weight loss as in HIV infection. -Acute sudden onset of bloody
diarrhea with abdominal cramps as in bacillary dysentry due to Shigellae
10. Severity: high, moderate or low grade? High grade fever made the patient unable to perform any activity,
interfered with sleeping and eating and the patients are usually kept in bed
N.B. Factitious fever: Patients with factitious fever are young and usually educated and are employed in health related professions.
Clue to factitious fever, include:
- Absence of toxic appearance despite high temperature readings.
- Lack of appropriate rise of pulse rate with fever.
- Absence of physiological diurnal variation in temperature.
N.B. Fever o(unknown (undetermined) origin (FUO): ls a term applied to febrile illness with temperature exceeding 38.3 °C that are of at
least 3 weeks duration and remain undiagnosed after 3 days in the hospital or after three outpatient visits.
N.B. Feeling cold and shivering both accompanies a rising temperature, while feeling hot and sweating accompany a falling
temperature. Feelings of heat and sweating also accompany menopause. Normally the body temperature rises during the day and falls
during the night. When fever exaggerates this swing, night sweats occur. Night sweats occur in tuberculosis and malignancy
Causes of pyrexia of unknown origin

Autoimmune hypersensitivity Familial – hereditary
Infection
diseases diseases
• Bacterial Rheumatoid Familial Mediterranean
diseases arthritis fever Hypertriglyceridemia
Systemic Rheumatic fever
infection:- Systemic lupus erythematosus
• Tuberculosis
• Brucellosis Neoplasms Thermoregulatory
disorders
• Salmonellosis Leuk Brain tumor
Localized infections:- emia Cerebrovascular
• Pneumonia Lymp accident
homa Hyperthyroidism
• Pyelonephritis Pheochromocytoma
(2) Viral diseases like cytomegalovirus, Granulomatous disease Miscellaneous
infectious mononucleosis and
hepatitis
• Fungal diseases like histoplasmosis Sarcoidosis Diabetes insipidus
and coccidioidomycosis Crohn's Factitious fever
• Parasitic diseases like disease Pulmonary
giardiasis, toxoplasmosis, embolism
and malaria
Pallor
Ask about:
1. Onset: Hemolysis and bleeding present acutely while most other causes of anemia present in more subacute or chronic fashion.
2. Duration:
3. Site: skin, mucous membrane, both ?
4. Progression:

Precipitated factors in G6PD: Fava bean, henna, benzene, Fever/infection, Methbrin, penicillin, aspirin
6. Relieving factors: blood transfusion, drugs…
External bleeding:
Skin rash, ,blood in urine, blood in stool, nose bleeding, mouth bleeding, menorrhagia
Internal bleeding:
Joint: pain/swelling
Neck soft tissue: SOB
Iliopsoas: abd.pain, distention, diarrhea
Brain: convulsion, vomiting, change in the mood
Hemolysis:
Jaundice
Color of urine and stool
Bone pain
8. Severity:
ask if the patient had: headache, dizziness, syncope, decrease activity, palpitation, SOB.
Past medical& surgical history:

may reveal a disease which is known to be associated with anemia, such as rheumatoid arthritis (the anemia of chronic disease), celiac
disease (iron and folate deficiency), and Crohn's (iron and vitamin B12);
surgery involving the stomach may lead to iron and vitamin B12 deficiency anemia, surgery involving the upper small bowel may lead to
folate deficiency, and surgery in the terminal ileum may lead to vitamin B12.
Family history: Hemolytic anemias such as the hemoglobinopathies and hereditary spherocytosis may be suspected from the
family history. Pernicious anemia may also be familial.
Social history: may provide a clue to the underlying cause:

painting may cause lead poisoning that leads to hemolytic anemia,
exposure to benzene in industry (or radiation exposure as with radiologists) may lead to leukemia,
and exposure to insecticides may lead aplastic anemia.
Example1 The condition started as exertional SOB that occurred gradually over two to three months, slightly relieved by rest and
blood transfusion, and aggravated by exertion. She had one similar attack one year ago for which she received two pints of blood and
resulted in complete improvement in her condition. She had failed two and half years ago to respond to iron course of therapy when she
felt at that time generalised fatigue and weakness. Six months later she had been subjected to further investigation and given daily oral
folate tablet after two pints of blood. She however neglected her medication for the preceding four to five months in a mistaken belief that
she had cured. She had healthy diet, no drugs ingested prior to this attack and no significant relevant medical illness. Both her father and
mother had a blood problem The diagnosis is hemoglobinopathy e.g. thalassemia
Example2 The condition started over the preceding three days as recurrent attacks of bone pain that was located mainly in the
upper part of his arm, mild at the start but soon became very severe likened trauma pain, dull ache in nature, similar to previous two
attack in this year, relieved slightly by rest and pain medication, and aggravated by movement. He had two similar attacks in the current
year each persisted for two to three weeks in a waxing and waning pattern. The patient had been kept on daily folate therapy when he
developed exertional SOB two years ago and received two pints of blood. His condition was associated with generalised weakness, high-
grade intermittent fever with sweating and occasional awareness of his beats. He had otherwise healthy diet, no drugs ingested prior to
this attack and no significant relevant medical illness. Both his father and mother had a blood problem
The diagnosis is vaso-occlusive crisis in sickle cell anemia
.

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(Questions you need to ask in each symptom and the reason behind your question)

By Falih Obaid Shamkhy

Part one : general history

Identity (demographic details)

Example : frequent bowel motion for 2 days before admission

Medical terms Patients description Medical terms Patients description

Dyspnea Shortness of breath (SOB) Melena Black tarry stool

History of present illness

1- A known case of …? DM, HT, epilepsy etc.

Past medical & surgical history

1. Pervious same symptoms or similar attack

Previous Jaundice (hepatitis), haematemesis, melaena, suggestive of portal

Menstrual & gynaecological history

1. Marital status (married, divorced ,separated ,widow)

Examples of single-gene inherited disorders

Social & occupational history

1. Chronic drug use: steroid , contraceptive , Warfarin , Heparin , Aspirin, etc.

 Name of the drug that the patient use

Specific history and DDX.

Cardio Vascular System

2. Onset: sudden? Gradual ?

3. duration : short? Long?

4. Character: heavy? Sharp? Tearing? Burning?

5. Severity: interfere with daily activity? Sleeping? Shouting? Levine sign?

6. Radiation: yes or not? Where?

7. Timing , progression , frequency: constant? Come in attack?

9. Associated symptoms: autonomic symptom? Fever? Cough? Dyspnea?

Family history : of heart attack ( MI, angina ), recent death

Social history: smoking

Common causes of Chest pain

Lung/ pleura Pulmonary embolism Pulmonary infraction, Pneumothorax, Pneumonia,

Shortness of breath (dyspnea)

2. Duration: short? Long?

3. Timing: night? Early morning? Day?

4. Course: continuous? Episodic( respiratory)? Progressive( cardiac) ?

5. Severity: on rest ? on exertion, dgree? NYHA classification ?

6. Aggravating factors: position(orthopnea)? Exertion? environmental exposure? Allergen?

7. Reliving factors: position? Medication? O2 ?

8. Associated symptoms: review of the CVS and respiratory system

Character of dyspnea in:

Pleural effusion: Gradual onset, worse on lying on the normal side

Pure mitral stenosis: Similar to left ventricular failure

Other causes: Guillain Barre, obesity, Scoliosis, kyphoscoliosis, myasthenia

Acute dyspnea Chronic dyspnea

4. Speed: fast? Slow? (ask the patient to tap it )

Past history: history of valvular heart disease or thyrotoxicosis

Common causes and patient description of palpitation

Pre syncope: feeling of impending loss of consciousness

5. Associated symptoms: CNS and CVS

Features helpful in distinguishing seizure from syncope (faint)

Common causes of syncope

Diabetic autonomic neuropathy

Ankle swelling or Body swelling in general

2. Onset: sudden, gradual?

3. Duration and progression: extend to other site?

4. Character: painful, painless? Itchy? Dusky, red? Pitting, non?

6. Aggravating factors: drugs, walking, immobility, nutrition, sleeping, menstruation

7. Relieving factors: diuretics, sleeping, resting

8. Associated symptoms: local and systemic

Causes of localized Oedema

Causes of not localized Oedema

N.B. generalized edema are: (fluid overload or hypoproteinemia)

Hypoproteinemia, particularly hypoalbuminemia,