HISTORY TAKING

HAEMOPTYSIS
CASE:A 35 YEAR OLD MAN,WHO
CAME AS REFUGEE TO UAE,5 YEARS
AGO,PRESENTS WITH HAEMOPTYSIS
AND WEIGHT LOSS.HE HAS BEEN
PREVIOUSLY FIT AND WELL.

By SIRAJUM MUNEERA
13901098

YEAR 3 MBBS

INTRODUCTION AND CONSENT:

HELLO,MR.________ I AM MS.SIRAJUM
MUNEERA,I AM A THIRD YEAR MEDICAL
STUDENT.I AM HERE TO ASK YOU FEW
QUESTIONS ABOUT YOUR HEALTH.IS THAT OK?
(IF PATIENT SAYS YES PROCEED,IF PATIENT REFUSES TRY
TO CONVINCE HIM,BUT BE CAREFUL NOT TO FORCE HIM)

SO YOUR NAME IS MR____________

WHAT IS YOUR AGE SIR?
WHERE ARE YOU FROM SIR? REFUGEE
WHERE WERE YOU BORN SIR?
ARE YOU MARRIED SIR?
HOW DID YOU GET TO THE HOSPITAL?
Note down gender,admitting date and
time,mode of admission(private
vehicle,ambulance)

PRESENTING COMPLAINT:
SO TELL ME MR.________ WHAT HAS BROUGHT
YOU ALONG TO SEE ME TODAY?
COUGHING BLOOD

ANY OTHER PROBLEM?

WEIGHT LOSS

HISTORY OF THE PRESENTING

COMPLAINT:
TIMING

WHEN DID YOU START COUGHING BLOOD ?

HAVE YOU VOMITTED THE BLOOD OR WAS IT
COUGHING THE BLOOD?if not
DID THE BLOOD APPEAR IN MOUTH EVEN
WITHOUT COUGHING? If not continue history
taking of hemoptysis
HOW DID YOU START COUGHING?
IS THIS THE FIRST TIME YOU ARE COUGHING
BLOOD?
(If the patient says no
WHEN WAS THE FIRST TIME YOU COUGHED
BLOOD?
WHAT DID YOU DO TO RESOLVE IT?)
WOULD YOU TELL ME MORE ABOUT THIS
EPISODE?
HOW LONG DID THIS LAST?
HOW LONG WERE EACH EPISODE BEFORE(IN
CASE patient had previous episodes)

HAS COUGHING OF BLOOD IMPROVED

WORSENED OVER THE TIME OR HAS IT BEEN
THE SAME ALL THE WHILE?

 WAS IT CONTINUOUS OR DID IT HAVE

INTERVALS?
DO YOU DO ANYTHING THAT RELIEVES YOU
FROM THIS?
DO YOU DO ANYTHING THAT WORSENS THIS?
DO YOU HAVE ANY CHEST PAIN,SHORTNESS OF
BREATH,WHEEZE,FEELING OF HEAVINESS IN
CHEST,ANY BURNING SENSATION,OR ANY
OTHER SYMPTOM WHICH YOU MIGHT WANT TO
TELL ME ABOUT?

COUGH

WOULD YOU TELL ME MORE ABOUT THE

COUGH?
HOW DOES YOUR COUGH SOUND?
DID YOU HAVE MUCUS ALONG WITH BLOOD IN
IT WHEN YOU COUGHED?if yes take history for
sputum also
DOES SOMETHING WORSEN YOUR COUGH?
DOES SOMETHING RELIEVE YOUR COUGH?
DOES YOUR COUGH INCREASE OR DECREASE
IN ANY TIME OF THE DAY OR NIGHT?
HAEMOPTYSIS

HOW MUCH BLOOD DID YOU COUGH?

 WHAT WAS THE COLOUR OF THE BLOOD?

(assess whether the blood is fresh or altered)
HOW OFTEN DO YOU COUGH BLOOD IN A DAY?
DID YOU HAVE MUCUS IN THE BLOOD?
IF YES,was it mixed in the blood?
SPUTUM:

HOW MUCH MUCUS DID YOU COUGH?

HOW OFTEN DO YOU SEE MUCUS WHEN YOU
COUGH?
WHAT IS THE COLOUR OF THE MUCUS?
DOES THE MUCUS FEEL THICK OR THIN?
DID YOU SEE STREAKS OF BLOOD MIXED IN
THE MUCUS?
DID YOU SEE BLOOD CLOTS IN THE MUCUS?
HOW DOES THE MUCUS SMELL?
DOES THE MUCUS HAVE ANY TASTE?
HAVE YOU SEEN ANY SOLID MATERIAL IN THE
SPUTUM?
WEIGHT LOSS

HOW HAS YOUR APPETITE BEEN RECENTLY?

ARE YOU UNDERTAKING ANY DIET?
HOW MANY KGS OF WEIGHT HAVE YOU LOST
OVER THE PAST MONTH?
HOW HAS YOUR WEIGHT BEEN IN PAST 6
MONTHS?

 DO YOU CHECK YOUR WEIGHT EVERYDAY?If

yes have you noticed any difference?(checking
for cancer cachexia)

Do you want to add anything which I might

haven forgotten to ask about?

Has this been affecting your every day

activity?if yes,How has it been a hindrance?

PAST MEDICAL HISTORY

WHAT ABOUT YOUR HEALTH OTHERWISE?
HAVE YOU HAD ANY SIMILAR COMPLAINT IN
THE PAST?
DO YOU HAVE ANY HISTORY OF DIABETIC
MELLITUS,HYPERTENSION,ANY RESPIRATORY
DISEASES,CYSTIC FIBROSIS?
DO YOU HAVE HISTORY OF CHILDHOOD
ASTHMA,HAY FEVER,MEASLES,WHOOPING
COUGH,ANY LUNG DISEASES LIKE
PNEUMONIA,TUBERCULOSIS,ANY SYSTEMIC
DISEASE?
DID YOU HAVE ANY HISTORY OF TUMOR OR
CANCER BEFORE?if yes
WHEN DID THIS HAPPEN?

 HAVE YOU TAKEN ANY CHEMOTHERAPY OR

RADIOTHERAPY FOR IT?
WHEN WAS THE LAST SESSION OF THE
THERAPY?
HAVE YOU BEEN HOSPITALISED BEFORE?
DID YOU HAVE ANY SURGERIES DONE?
ANY TIME WHEN YOU HAVE BEEN
ANESTHETISED?
ANY HISTORY OF NEUROLOGICAL PROBLEM?
WOULD YOU LIKE TO ADD SOMETHING?

FAMILY HISTORY
WHAT ABOUT THE HEALTH OF YOUR FAMILY?
DOES ANY ONE OF YOUR PARENT HAVE CYSTIC
FIBROSIS
ASTHMA,ECZEMA,HAYFEVER,COPD,TUBERCUL
OSIS,LUNG CANCER?
DOES ANY ONE OF YOUR CHILDREN OR
SIBLING HAVE ANY OF THE DISORDERS I ASKED
ABOUT?
DO THEY HAVE ANY HISTORY OF DIABETIC
MELLITUS,HYPERTENSION,ANY RESPIRATORY
DISEASES?
IM SORRY TO ASK,BUT HAS THERE BEEN ANY
DEATH IN THE FAMILY?IF YES AT WHICH AGE
DID THE PERSON DIE?
WHAT WAS THE CAUSE OF DEATH?

DRUG HISTORY

DO YOU USE ANY MEDICATION REGULARLY?

If yes,ask
WHY ARE YOU TAKING THESE MEDICATIONS?
DO THEY HELP YOU?
HOW MANY DO YOU TAKE PER DAY?
WHAT IS THE DOSE?
HOW LONG HAVE YOU BEEN ON THIS
MEDICATION?
HAVE YOU EXPERIENCED ANY PROBLEMS WITH
THIS DRUG?
HAVE YOU BEEN TAKING THEM REGULARLY?
DO YOU HAVE ANY DRUG ALLERGIES?
ANY RECENT CHANGES IN MEDICATION?

REVIEW OF SYMPTOMS
AS QUESTIONS ON WEIGHT LOSS APPETITE HAVE
BEEN ASKED BEFORE ,HISTORY TAKING PROCEEDS
WITH OTHER WELL BEING QUESTIONS
HOW HAS YOUR HEALTH BEEN ?
HAVE YOU BEEN ON REGULAR ENERGY
LEVELS?
HOW HAS YOUR MOOD BEEN RECENTLY?

 DID YOU HAVE ANY EPISODE OF LOSS OF

CONSCIOUSNESS?
CARDIOVASCULAR:do you have any chest pain
on exertion,palpitations,pain in legs on
walking,ankle swelling?
GI :do you have any difficulty in
swallowing,any
nausea,vomiting,indigestion,change in bowel
habits,constipation,change in colour of stools?
GUT:do you have any pain while passing
urine,any change in frequency of urinating,or
blood in the urine or any difficulty starting it?is
the stream of urine continuous,does it have
any terminal dribbing or discharge?do you
have any erectile difficulties?
NERVOUS SYSTEM:do you have any
headache,dizziness,faint
episodes,fits,numbness or tingling
sensation,weakness,any visual
disturbance,hearing problems,memory and
concentration changes?
MUSCULOSKELETAL SYSTEM:do you have any
joint pain,swellin,any problem in moving
around,or unintended falls?
ENDOCRINE SYSTEM:do you have any heat or
cold intolerance?
Has there been any change in sweating?

 OTHER: have you noticed any abnormal

bleeding or bruising?any skin rashes?

SOCIAL HISTORY
SO TELL ME ABOUY YOUR EVERY DAY
ROUTINE?
WHERE DO YOU LIVE HERE?
DO YOU FEEL COMFORTABLE CLIMBING STAIRS
IF YOU TAKE THEM ANY TIME?
WHAT DO YOU WORK AS?
HAVE YOU WORKED BEFORE IN ANY OTHER
FIELD?
IF unemployed do you receive pensions?
How much pension do you receive?
HAVE YOU BEEN ABLE TO SUPPORT YOUR
FAMILY ?
DO YOU RECEIVE ANY OTHER BENEFITS AND
ALLOWANCES?
DO YOU FEEL THIS HAS BEEN SUFFICIENT?
DO YOU FEEL YOU RECEIVE ENOUGH
PRACTICAL AND EMOTIONAL SUPPORT?
DOES THIS PROBLEM AFFECT YOUR ABILITY TO
WORK?
DOES IT AFFECT YOUR MOOD?

 DOES IT HINDER YOU FROM PERFORMING

DAILY ACTIVITIES?
DOES IT HAVE AN IMPACT ON YOUR RELATIONS
WITH LOVED ONES?
WHAT ARE YOUR HOBBIES?
WHEN IS THE LAST TIME YOU TRAVELLED?
If relevant,
WHICH COUNTRY DID YOU VISIT?
HOW LONG DID YOU STAY?
HOW IS YOUR NORMAL EATING HABITS?
HAVE YOU BEEN VACCINATED REGULARLY
SIR IF YOU DONT MIND MAY I ASK YOU SOME
PERSONAL QUESTIONS

DO YOU SMOKE?if no HAVE YOU SMOKED

BEFORE?
IF YES,
WHICH CIGARETTE DO YOU USE?
HOW MANY PER DAY?
HOW LONG HAVE YOU BEEN SMOKING?
DID YOU EVER TRY TO QUIT?
IF YES,
WHAT MEASURE DID YOU TAKE?
DID IT HELP?
DO YOU DRINK ALCOHOL?
IF YES,
WHICH ONE DO YOU DRINK?
HOW MUCH QUANTITY?

 HOW FREQUENT?
HOW LONG HAVE YOU BEEN DRINKING?
HAVE YOU EVER FELT THE NEED TO CUT DOWN
ON DRINKING?
HAVE YOU FELT ANNOYED BY CRITICISM ON
DRINKING?
HAVE YOU FELT GUILTY FOR DRINKING?
HAVE YOU TAKEN ALCOHOL AS THE FIRST
THING IN THE MORNING?
DO YOU USE ANY RECREATIONAL DRUGS LIKE
POT,COKE OR ANY OTHER?
HAVE YOU EVER INJECTED DRUGS?
HAVE YOU SHARED NEEDLES?
ARE YOU STILL USING THEM?if yes
How often?
Thank you for the cooperation.we would need
to order a few further investigations for
reaching a proper diagnosis and we ll let you
know of your problem..there is absolutely no
need for being anxious we are here to help
you.lets hope for the best.ill see you once the
reports are ready.