Neurogenic Bladder: UMN vs LMN: Physiology made easy.

Basic Physiology of Micturition

Micturition is a spinal reflex modulated by CNS.

Neural control of micturition.
Source: http://physiologyplus.com/micturition-reflex-steps/

The pre-frontal cortex is responsible for the cognitive control of the micturition which analyses the signals from bladder and conveys signals according to void or not to void depending on the social setting.

The higher control of micturition is mediated by pontine micturition centre (PMC) from where nerve fibre arise and travel along the lateral columns bilaterally. It is the mechanical control of micturition. It coordinates the function of baldder and sphincter.

The Sympathetic fibres are thoracolumbar (T10-L2) outflow of nerve fibres and terminate in the hypogastric ganglion.

The Parasympathetic fibres are sacral (S2-S4) outflow.

The voluntary control over the external urtheral spincter is mediated by somatic fibres of Pudendal nerve. 

Learn about Cranial nerve examinations

Intact Spinal cord is essential for normal micturition as it serves as a intermediate relay between the brain and the sacral center of micturition. Sacral reflex center is the primitive voiding center which is responsible for infants diaper need, since there is a continuous cycle of bladder filling and voiding. The higher mental function gradually enhances in kids as they are growing and accordingly they are trained to use toilet with their enhanced higher mental function.

	Sympathetic	ParaSympathetic
Bladder (Detrusor Muscle)	Relaxation	Contraction
Bladder Neck	Contarction	Relaxation

The bladder wall is relaxed and the neck constricted with sympathetic stimulation which allows for retention of urine. The parasympathetic stimulation causes bladder wall to contract and sphincter to relax easing the voiding of urine.

Learn about the analogy of skeletal muscle and bladder in UMN and LMN lesions. 

Analogy of Skeletal Muscle contraction and Bladder

LMN vs UMN Lesion : Effect on Bladder

There is a lot of analogy between skeletal muscle contraction and bladder.

In the absence of higher control, overdistension of bladder causes reflex detrusor contraction. Similar to     the muscle stretch reflex mediated by spindle fibre in skeletal muscle.

The upper motor neuron lesion of the brain and the spinal cord causes features similar to that of the UMN lesion of in the muscle characterized by Spastic bladder/ Hypertonic baldder.This is due to the reflex detrusor contraction. There is increased tone of the detrusor muscle. However, the bladder contracts with overdistension, the sphincter does not relax causing bladder sphincter dyssyenrgia. This causes urgency and urge incontinence. The volume of residual urine in the bladder is increased which causes high risk for UTI and chronic renal failure due to obstructive uropathy. The site of the lesion is generally the Spinal cord or pons or higher. There is no gross dilatation of the bladder due to the reflex contraction which results in low volume high pressure inside the bladder.

Learn about the plantar reflexes and its variants with video demonstration

The lower motor neuron lesion to the fibre supplying bladder causes overflow incontinence. This occurs because bladder is overdistended however the reflex detrusor contraction doesnot comes into play. So what happens is the bladder leaks over time when it is beyond its holding capacity without the detrusor muscle contracting. The bladder is grossly dilated resulting in high vomule and low ressure inside the bladder.This can be described as flaccid or atonic bladder similar to flaccid paralysis of muscles in LMN lesion.The patient cannot initiate the micturition. The site of injury is generally the sacral fibres or peripheral nerve fibres

The last type of neurogenic bladder ocuurs due to injury in the prefrontal cortex which is responsible for social control of micturition. It allows us to find us to micturate in appropriate place. The patient doesnot have the sense of bladder fullness. They have trouble initiating micturition and they micturitate at inappropriate places.

Character	UMN Type	LMN Type
	Spastic Bladder	Flaccid Bladder
Tone	Hypertonic (Increased)	Hypotonic (Decreased)
Volume	Normal or small	Large
Detrussor contraction	Involuntary intermittent contractions (Overactiity)	Absent (Underactivity)
Pressure	High	Low
Incontinence type	Urge	Overflow
Symptom	Urgency and Frequency nocturia Leaking of urine	Dribbling of urine Erectile edysfunction in men
Retention	Incomplete bladder voiding (Detrussor-Sphincter Dyssynergia) Uncoordinated bladder contraction and sphincter relaxation	Detrusor Aflexia
Conditions	Spinal Cord damage above T12 Cerebrovascular accidents	Spinal cord damage at S2-S4 Peripheral Nerve injury Acute Stage of spinal cord injury Cauda Equina, Conus medullaris

  

Source: Davidson, Merck’s Manual, Medscape

Sample History: Diarrhoea and vomiting in infant.

Sample Pediatric history writing : Vomiting and Diarrhoea

(This case is special to me because this history is digital version of the history and clinical examination I presented in my ninth semester pediatrics board examination. Most of the points are just jotted down which needs linguistic description as you present them. The parenthesized and italic words are the way it is said while the words that are just parenthesized are the justification in any point where extra elaboration may be needed. Many points may be missing but I have not corrected the things I have written in the exam sheet. Since this was a piece of exam, so many points may be missing and complete elaboration is language is absent. So I would like to apologize for that.)

Name: Ms. Pariyar

Age: 11months

Sex: Female

Address: Nala

Father: Mr. Pariyar, 23yrs Farmer,  Class 7

Mother: Mrs. Pariyar, 21yrs housewife, illiterate

Informant: Mother, hence reliable.

(Always write the level of education and profession of parents to know the level of their comprehension and their approach to child health. The informant is important as mother is the one who take cares of the child and knows the exact chronology and series of event. While other informants such as father, grandparents are not the first hand handler of the child and may only elaborate what they have been told by the mother and may not know all the details.)

Date of admission: 23^rd September 2015 to ER @ 2:00pm

Date of Examination: 24^th September 2015

(Ms. Pariyar, 11yrs girl from Nala, daughter of Mr and Mrs pariyar was presented to DH ER yesterday at 2:00 pm with complains of )

Chief Complaints

Vomiting for 5 hours x 1 day

                Diarrhoea for 1 day

(The history is given by mother, hence the history is reliable)

History of Present illness

According to the mother, the child was active and playful 2 days back, then she developed 8-9 episodes of vomiting, which initially contained the ingested food material (milk) and later turned greenish and watery. It was about 2 teaspoon full in each episode, foul smelling and non-projectile.

After around 6 hours, the child developed diarrhea, 10-12 episodes/day, watery with mucoid content, was foul smelling but did not contain blood in the stool. The child cries while passing the stool but not during micturition.

There is also history of fever associated with diarrhea which was mild, continuous and not associated with rash and abnormal body movement.

There is no loss of appetite, drinks vigorously. Mother gives history of infrequent micturition compared to previous times.

No cough, no shortness of breath.

No loss of consciousness or avoidance of bright light.

Treatment history:

The patient was bought to DH 2 hours after the onset of vomiting, where she was provided with IV medication which subsided the vomiting. The child has been receiving IV fluids and the child is improving as vomiting has subsided but diarrhea is yet to improve.

Past history

Birth

ANC: 6 ANC visits, taken folic acid, iron, calcium, 2 TT vaccines.

Natal: Cesarean delivery at DH for prolonged labor, cried immediately after birth, passed stool and urine within 24 hours.

Post natal: breastfed within 24 hours of birth.

(The mother had regular ANC visits and had taken folic acid, iron, calcium and both the TT vaccine. She underwent CS at DH for prolonged delivery. The child cried immediately after birth, the child cried immediately after birth, passed stool and urine within 24 hours. The child was breast fed within 24 hours of birth. The post natal period was uneventful.)

(The child greater than 3 years all the prenatal, natal and postnatal history may be uneventful and can be skipped without telling the minor details unless it has significant relation to birth history. The child is breast =fed generally within 1 hour of birth but since this a CS case, so the breastfeeding may have been delayed.)

Immunization

At birth BCG

6 weeks Hep B, Hib, DPT, OPV, PCV

10 weeks Hep B, Hib, DPT, OPV, PCV

14 weeks 2 vaccines Hep B, Hib, DPT, OPV, IPV (2 vaccine is the description given by mother, Pentavalent in one vaccine and IPV in the next)

9 months MR + PCV

12 months and 15 months remaining.

(The child has received the vaccination as per the National EPI Schedule for her age, the vaccinations of 12 months and 15 months are remaining.)

(All the vaccine mentioned need not be read one by one, rather National EPI Schedule includes all. Mother can describe at what age, how many shots of vaccine and oral drops the child has received. Based upon that we can confirm If the child has received the necessary vaccination or not.)

Nutrition

                Exclusively Breastfed for 1 month

                Then added powder milk

                After 3 months: Sarbottam pitho

Currently Breastfed every 1-2 hourly for 10-15 minutes

Dal + rice small bowel 100X2 gm = 200 gm calorie: 260 kcal

Snack Biscuit 3 pieces 3x 20 = 60kcal

Total 340 kcal

8 kg 800 kcal  

(The child was exclusively breastfed for 1 months and then weaned with powder milk. After 3 months of age sarbottam pitho was added to her diet. Currently she is breastfed every 1-2 hour for duration of 10-15 minutes. Besides she is fed with 2 small bowel of regular meals and 3 pieces of biscuit in snack. The total calorie intake besides breast milk is 340 kcal and the expected calorie intake needed is 800kcal)

(Calorie deficit can not be commented upon as the chold is still feeding on milk. If breast milk does not form the significant source, the calorie defecit must be calculated)

 

Development

Stands with support and walks with support (Motor)

Pincher grasp present (Fine Motor)

Uses bisyallable words and says baba and ama (language)

Interacts with mother (Social)

Past History

No history of similar illness in the past.

No chronic illness like asthma.

Family history

Mother had similar illness 1 week back.

No history of chronic illness.

(Pedigree drwaing is must in pedia, see the image) 

Socioeconomic history

Belongs to a well sustained middle class family.

Has provision of sanitary latrine and uses soap.

Drinks water from tap and spring water but does not boil the water.

Drug and Allergy history: Not present

History of Consanguinity: Not present

History of Contact to TB: Absent

Examination

Ill looking, fairly built child, is lying in supine position with yellow IV cannula with fluid flowing through the cannula.

Vitals

Pulse: 136bpm, regular euvolemic

BP: (not feasible)

RR: 47bpm , regular, thoracoabdominal

Temperature : 38^oC

Anthropometry

Length:  74cm, which lies between the 10^th  and 25^th centile.

HC (head circumferene): 46 cm lies between the 10^th and 25^th centile

Weight: 8 kg

MUAC : 14cm (Mid Upper Arm circumference)

(The anthropometry data are plotted in a standard growth chart and the centile is measured or the expected values of various can be measured using various formula and the percentage of the expected and the observed can be calculated.)

>>Learn normal anthropometry values and formula to calculate them in pediatric.

Head to Toe examination

Hair looks normal in color and texture.

Fontanels are not sunken.

No discharge and redness of eyes

No dryness of eyes or sunken eyes

No nasal discharge and congestion

Mouth and oral cavity looks normal with 2 lower incisors and 1 upper incisors

Skin surface looks normal

No icterus, pallor or cyanosis.

Hydration status looks normal.

Abdominal examination

On inspection

The abdomen is protuberant and the umbilicus is centrally placed. All quadrants moving correspondingly with respiration. No visible pulsation, peristalsis or scar marks.

All quadrant moving corresponding with respiration.

Hernial orifices intact.

Perianal erythema present.

On palpation

Abdomen is soft, non tender and no local rise in temperature.

On superficial palpation, no masses palpable.

Liver is palpable 2 cm from the right costal margin which is soft, non tender and the margin is regular.

Spleen is not palpable and kidneys are not ballotable.

Kidneys are not ballotable.

On percussion, normal tympanic note is present all over the abdomen

On auscultation, normal bowel sound heard with 3 bowel sound/minute heard.

Chest: B/L equal air entry with normal vesicular breathe sound (NVBS).  S1S2M0

CNS/MSK: Grossly intact

Provisional diagnosis:   Acute Gastroenteritis

Differential Diagnoses:                 Enteric Fever

                                                Viral Hepatitis

                                                Secretory Diarrhoea 

History Writing: A case of Premature rupture of Membrane

(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.)

>>All the points that should not be missed while taking a Obstetrics History.

Patients Particulars (to be enlisted rather than written in text)

Name: Sita Koirala

Age: 28years

Address: Dhulikhel

Religion: Hindu

Marital status: married to Ram Koirala

Married for 7 years

Occupation: Housewife

Date of admission: 2016/03/05

Place of presentation: Emergency Department

Date of examination: 2016/03/07

(Mrs Sita Koirala, 23 years lady, a housewife from Dhulikhel, married for 7 years, presented to DH emergency with)

Complain of

Cessation of menstruation for 8 months

Pain abdomen for 1 day

PV leak for 3hrs

Menstrual History

Last Menstrual Period 2015/07/01

Expected Date of delivery 2016/04/07

Period of gestation: 36 WOG

Menarche: 13 years

Regularity of cycles and its length: Regular every 28 days

Duration of menstrual flow 3-4 days

Passage of clots (-)

Dysmenorrhea (-)

Number of pads changed per day and its soakage.(3 pads/day, partially soaked)

(She attained her menarche at the age of 13 years with regular cycles of 28 days and menstrual flow of 3-4 days. She changes 3 partially soaked pads per day with no history of passage of clots and severe crampy pains during her menstruation)

Obstetrics History

Marital History

Duration of marriage 7 years

Age at marriage 21years

Parity Index (G3P1A1L1)

She is a Gravida 3 Para 1 Abortion 1 and Living 1 lady and was 23 years at the age of her first child birth.

She has a 5 years old boy, delivered normally at Dhulikhel Hospital with birth weight of 2.8 kg. Antenatal, natal and postnatal period was uneventful.

She had a spontaneous abortion 1 year back at 10 weeks of gestation for which she underwent suction and evacuation at Dhulikhel hospital. No complications were noted.

Contraceptive history

She used OCP immediately after her marriage but discontinued after 3 cycles of use. 3 months after the delivery of her child she inserted cupper T. She removed copper T one year back. She had regular cycles during the use and no complications were noted in between.

History of Present pregnancy

First Trimester

She confirmed her pregnancy after 1.5 months of cessation of menstruation at local clinic by urine pregnancy test. She had complains of nausea and vomiting but was not severe enough to get hospitalized. She also complains of urgency and frequency but no burning micturition. Mild soreness of breast was present. But she does not give history of fever, pain abdomen or per vaginal bleeding.

She had 1 ANC visit in the 1st trimester where her blood and urine examination was done and was told to be normal. She took Tab Folic acid. USG was not done. No exposure to any radiation or intake of any other non-prescribed medication.

Second trimester

Cessation of menstruation continued. There was progressive enlargement of abdomen and breast.

Quickening was experienced at 5 months of gestation.

She had 3 ANC visits. She had routine checkup and was told to be within normal limits. She took tab iron and tab calcium regularly. Tab Albendazole was taken at 5th month of gestation. 2 doses of TT vaccination was taken month apart. Blood test after consumption of glucose and water was done which was told to be normal. USG was done at 5th month and told to be normal.

She had no complains of urgency, frequency and burning micturition. No complains of headache, blurring of vision, shortness of breath. No history of fever, PV bleeding or PV discharge.

Third trimester

Cessation of menstruation continued. There was progressive enlargement of abdomen and breast. She gained a total weight of 10 kg during her pregnancy. She is perceiving fetal movements.

She had 4 ANC visits, continued the intake of tab Iron and calcium.

No complains of urgency frequency, No swelling of limbs and shortness of breath. No complains of headache, blurring of vision, fever, PV bleeding or PV discharge.

History of Present illness

According to the patient she was apparently well 1 day back, then she gradually developed lower abdominal pain which was insidious on onset, on and off. No radiation of the pain. No aggravating and relieving factors were present. She also gives history of per vaginal leaking 3 hours back which was plenty enough to soak her clothes which aggravated her abdominal pain. The fluid was clear and not stained with blood or green colored discharges.

She is perceiving fetal movement.

She does not give history of PV bleeding.

No history of fever, no urgency frequency or burning micturition.

No PV discharge.

No history of nausea, vomiting, diarrhea or abdominal distension.

No history of trauma.

No cough, cold or chest pain.

History of Past Illness

No history of chronic illness like Hypertension, Diabetes Mellitus, Epilepsy, Rheumatic Heart Disease, Bronchial Asthma, or Hypothyroidism. No past history of tuberculosis or jaundice.

No prior surgeries done. Not under any medication for any chronic illness.

No known allergy to any food, drug or other substances.

Personal History

She is a non- smoker and does not consume alcohol. She consumes non vegetarian diet. She has normal bowel and bladder habit and has adequate rest.

Family History

No history of chronic illness in the family. No history of congenital anomaly in the family. No history of consanguinity. No history of multi-fetal pregnancy or recurrent abortion in the maternal lineage.

Socioeconomic History

She belongs to a well sustained middle class family with good relation in the society. She has completed class 12.She lives in a modern house with good provision of clean drinking water and sanitary latrine.

My Provisional diagnosis based upon history is

G3P1A1L1 at 36 WOG with Premature Rupture of Membrane.

Have problem with gravida para. Try some problems 

*** 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.*** 

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.***