History Writing: A case of COPD

(Italicized words and parenthesized words and  sentences are for readers purpose only not to be read when presenting a case. The letters In Blue are points of special interest to be discussed later.

All the patients may not have the same symptoms at presentation and the same risk factors, so history taking should always be INDIVIDUALISED than generalised to a standard sets of check list.It is always RECOMMENDED to ask the patient their problems and the question associated with the problem as per the need.

Interpersonal variations are always exists in the way the history is taken and written. Pattern, format and style of history taking and presenting are subject to change as per institutional protocol and region.Please kindly follow the system that is acceptable in your context.)

A case of COPD

Patient Particulars

Name : Mr Magar

Age :  68 years

Sex: Male

Religion: Hindu

Occupation : Farmer

Marital Status : Married

Address: Ramechhap

Date of admission : 24^th August 2017

Date of examination : 29^th August 2017

Mode of admission: Emergency Room

(Mr Magar, 68yrs gentleman, a married, hindu, farmer from Ramechhap presented to XYZ hospital emergency 5 days back with )

Chief complaints

1.     Shortness of breath x 12 years aggravated for last 5 days

2.     Fever x 5 days

History of Present illness

According to the patient,  he was apparently well 12 years back, then he graduallly developed shortness of breathe which was initially present while walking uphill (MMRC grade 1) and gradually progressed over time and had to stop while walking about 100m on level ground (MMRC grade 3) in 12 years time. But for the past 10 days, the shortness of breathe is severe enough to compromise his daily activity (MMRC grade 4). Mild improvement was seen after use of inhalational drug.Patient uses 2 pillows to sleep (orthopnea) and gives history of occasional sudden awakening at night with severe air hunger and has to stand up and open window before the symptoms are relieved(PND). The shortness of breath is associated with cough and sputum production. He has bouts of cough more in the morning, on and off, aggravated by smoking and exposure to dust and cold and has mild chest pain. The patient also gives history of sputum production which is thick , mucoid, whitish in color, about a tablespoon full and non foul smelling. There is no blood in the sputum. But for the last five days the sputum is more copious, around a cup full and the color has changed from white to yellow.

The patient gives history of high grade fever for 5 days, insidious in onset, on and off,  more in the morning, associated with chills but no rigor and sweating. The temperature was not documented at home.  Patient complains of generalised weakness and muscle pain. No history of rashes, sore throat, headache.

The patient does not gives history of palpitation, lightheadedness and central chest pain. No complains of bluish discoloration of face and lips at the bouts of coughing (No cyanotic spell at end of cough). No swelling  of the limbs and adbomen (No corpulmonale).

No history of weight loss, no anorexia and easy fatigualbility. (Generalised symptoms)

No diarrhoea, vomiting, pain abdomen or abdominal distension. No dark colored stool or yellowish discoloration of skin. No history of burning micturition, urgency or frequency. (No Other foci of Fever )

No abnormal body movement, excessive drowsiness or confusion. No complains of headache (No chronic CO2 retention), photophobia and stiffness of the neck. (No other foci of fever)

No joint pain, pus draining sites or history of trauma.

History of past illness

The patient gives history of similar illness 2 years back for which he was hospitalized and was managed with oxygen and Iv medications. He had TB for which he completed a course of 6 months of treatment  15 years back. No other chronic illnesses like DM, HTN, Epilepsy. No history of any surgical intervention.

Personal history

Patient is a chronic smoker and has consumed about 40-45 pack years of cigarette (including bidi and hookah) for the past 50 years. But has stopped smoking for the last 2 years . Patient was a chronic alcoholic and consumed around 1 manas of locally made  alcoholic beverage (local unit = 500ml, assuming 30-40% of alcohol) which corresponds to for 1.5-2 units of alcohol for the  last 40 years but has stopped consuming for last 2 years.

He is non vegeterian and has normal bowel and bladder habit.

Sleep pattern is occasionally disturbed by sudden onset of severe shortness of breathe.

Family history

He has 8 members in the family.

No similar illness in the family.

No chronic illness like DM, HTN, TB or any cancers in the family.

Socioeconomic history

He belongs to a poor family. He uses fire wood and cattle dung cake for cooking food. The ventilation is inadequate and there is  congestion of smoke inside the house. The roof is thatched and they store grain in the same room they use for daily purposes. They have adequate provision of clean drinking water and toilet facilities.

Drug and allergy history

He has been taking from inhalation drug prescribed 2 years back but is not fully complaint with drug. No use of any drug for prolonged duration.  No known history of allergy to any drug, food or other substance.

Summary

58 years chronic smoker with 40 packs years of smoking, with previous history of PTB 15 years back, presented with SOB with MMRC grade 1 initailly, progressed to MMRC grade 3 over 12 years, associated with mucoid, scanty sputum more in the morning. But recently  SOB has been worse (MMRC grade 4 ) with high grade fever and purulent sputum for the last 10 days.  The patient is a chronic alcoholic, uses firewood to cook and has been taking inhalational medication irregularly. Patient gives history of similar episode 2 years back.

(We generally do not include negative history in the summary. This includes only the positive points)

Provisional Diagnoses based upon history

Acute exacerbation of COPD

Differential diagnosis

Pneumonia
Pulmonary Tuberculosis
Interstitial Lungs disease
Bronchial asthma
Lungs carcinoma

Learn How to write the chest examination.

The following table show what is the significance of most of the points mentioned in the history described above. Parenthesized are the point of interest in that specific condition. The positive (+) and Negative (-) sign here are to signify the presence or absence of the symptoms or history is favoring or rejecting any of the differential diagnoses. The greater the number of signs, the stronger is the favoring point or rejecting point .

History	Points of interest	AE of COPD	Pneumonia	Pulmonary TB	Asthma	Interstitial Lungs Disease	Lungs Cancer
Patient particulars	Age 65 yrs	++	+/-	+/-	-	++	+++
	Occupation	+ (Exposed to dust )		? labourous job … undernutrition (poor)	++ (exposed to dust, allergen, pollen, animal danders)	++ (Exposed to dust )
Chief complain	SOB x 12 yr	+++	-	-	+	+++	+/-
	Increased for past 5 days	+++ (Acute on chronic )	+++ (precipated under some underlying condition)	+	+	-	-
	Fever for 5 days	+++ (acute exacerbation otherwise absent)	++++ (active infection )	+ (Chronic infection)	-	-	-
HOPI	MMRC Grade 1 to 3 in 12 years	+++ (insidious onset )	-	+ (insidious onset but 12 years too long )	++(	+++ (insidious onset )	++ (insidious onset but 12 years too long )
	MMRC grade 4 in 5 days	+	+++ (rapid progression)	+	+++	--- (Rarely acute exacerbation)	++
	Mild improvement with inhalational drug (? SABA)	++			+ (Good improvement seen in early stages of the disease)
	Orthopnea	? Corpulmonale				Exposed to dust
	PND/ night symptoms	++			+++ (Rather night symptoms)	++
	Cough in morning	+++ (Chronic Bronchitis)	+	+	+ (More on night)	+
	Mucoid non purulent scanty	++	-(Purulent)	++	++	+	+/-(Serous /  Mucoid)
	Recently purulent, copious and yellow	-	+++	+++	_	---	-
	High grade fever		++ (Active Infection)	+ (Low grade fever for prolonged duration)		-
	Generalised weakness	+ Chronic poor respiratory effort	++	+	+	+ (Chronic poor respiratory effort)	+++ (more generalised symptoms)
Neagtive hsitory	NO hemptysis		+/-	--- (Commonly seen)			--- (Commonly )
	No weight loss			--- Commonly seen			---- Commonly seen
	No anorexia			--- Commonly seen			---- Commonly seen
Past history	Similar illness in past	++ (recurrent infection)		+ Risk factor	+++ Acute exacerbations of asthma
	PTB and ATT therapy	Risk factor		Risk Factor
	No DM ( not immuno compromised)		Risk	Risk
Personal history	40 pack years smoking	+++		++	++	++	++++
	Alchohol		+(aspiration)	++			+
	Disturbed sleep	PND			Night symptoms
Family history	8 member			Overcrowding
	TB	Risk		Contact history absent
Socioeconomic	Poor family			Risk factor
	Indoor pollution	++++ Precipitates		++ Risk factor	++ Risk factor		Risk factor
	Thatched roof and grain storage (? Fungal Allergen)				-- Risk factor
Drug allergy	Inhalational drug	++ ? Salbutamol for acute exacerbation			++ ? Salbutamol fro acute exacerbation	++ Bronchodilators
	No prolonged Drug therapy (Steroids, NSAIDS, aspirin , immunomodulators)			-- Reactivation of TB (steroid, immunomodulator drugs)	-- Aspirin, NSAIDS precipitates	-- Use of bleomycin, amiadarone, metho-trexate can cause pulmonary fibrosis
	History of Atopy				--- STRONG RISK FACTOR

DISCUSSION

Why do you think this is COPD?

All the point mentioned in Summary are the points are in favor of acute exacerbation COPD most likely secondary to a bacterial infection. Always tell your point in the same fashion you presented your history and just do not jump directly to the Chief complains or the history of present illness. Because age, occupation is of equal significance. The presence of past infection, risk factors such as previous history of PTB that can cause cavitary changes in lungs and other damages to lung parenchyma causes COPD. Risk factors such as smoking, use of firewood all those should be mentioned from TOP to BOTTOM.

Why not other condition?

Though TB has insidious onset and progression, but duration as long as 12 years may not be seen in PTB and Cancer. The patient may not last such a long duration with such active and significant morbidity.  Active TB develops generally over months to rarely few years. TB has low grade fever arising for more than 15 days or more and high grade fever only if there is a super infection upon the immunocompromised state of TB. But no other gross foci of fever are seen in this condition other than the lungs. Presence of Diabetes would have precipitated PTB.

The sputum was initially mucoid and whitish suggesting a chronic lung condition, which when precipitated by active infection may cause change in the sputum amount and color, most likely pneumonia than TB. The presence of hemoptysis could have strongly suggested TB but on its absence we can not rule out TB. The more generalised symptoms of weakness is present but anorexia is absent. The sudden aggravation of shortness of breath can not be justified unless there is development of pulmonary effusion in PTB.

However we do not see orthopnea, PND in TB. Rather PND, Orthopnea develops if the patient has left sided heart failure, and some times in pulmonary HTN.  Cor pulmonale secondary to COPD can cause pulmonary HTN and left sided heart failure to cause PND and Orthopnea. PND type acute bouts of SOB can be seen in Bronchial asthma as its night symptoms but asthma is less likely seen in elderly but  we can't say its Unlikely. The cough is more in the evening and night rather than morning but asthma can be precipitated with cold and dust.

The risk factor such as previous history of PTB treated with antitubercular therapy, overcrowding, poor socioeconomic condition can support the diagnosis of TB. Similarly, presence of risk factors like chronic cough aggravated with dust and smoke favors asthma. Absence of atopy is however against the asthma.

Interstitial diseases are insidious onset and progresses over a long duration of time. However there is rarely any features of acute exacerbation, rather they develop signs of pulmoary hypertension and Orthopnea, PND and right heart failure would be more signifcant. Similarly, the risk factors such as farming, use of smoking and exposure to indoor pollution can favor the diagnoses.

Carcinoma can be ruled out in the presence of more acute symptoms and more very very long onset of symptom which may not justify the presence of Carcinoma. No hemoptysis, no weight loss, No other systemic complains besides generalised weakness may not also favor malignacy. But for his age we just can not rule out maligncancy.

This discussion is incomplete and just a review of how things can be done. Depending upon what you have written in your history you have to support your provisional diagnosis. Answering a examiner would not be a big deal if you can sort out the informations in your mind, thesame way I have presented in the table, the points that favors any diagnosis and what was needed or absence of which make any of your provisional diagnosis unlikely.

Since, history taking can not be sufficient to rule out all other differential diagnoses the examination is must. So we don not have to worry if we can not  make a single provisional diagnosis just from history. But you should be able to rule out 2-3 differential diagnoses by the time you complete your history. Even on the completion of examination, it may not be crystal clear but still you can rule out more of diagnoses. Still we have diagnostic tools to come to conclusion. So , history taking is just a part of this process and not a complete process in itself. So, Don’t worry even  if you confuse yourself or examiner at the end of history taking.

*** Disclaimer : This is a hypothetical case and is not a real life scenario. However, the condition is so common and prevalent, it is a coincidence if it matches with the life of any. This case is solely for educational purpose with no intentions meant otherwise.***