Chest pain

Exploring symptom

• Pain
  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Timing
  • Exacerbating/relieving factors
  • Severity

Relevant system reviews

• General
  • Fever, sweats
• Cardiorespiratory
  • Palpitations, SOB/wheeze, cough, sputum, haemoptysis, leg swelling

Differential diagnoses and clues

Cardiovascular:

Myocardial infarction	-Crushing central chest pain -Radiates to neck/left arm -Associated nausea/SOB/sweatiness -Cardiovascular risk factors
Angina	-Cardiac-type chest pain -Associated with exertion -Relieved by rest
Aortic dissection	-Tearing chest pain of very sudden onset -Radiates to back -Pain in other sites, e.g. arms, legs, neck, head
Pericarditis	-Retrosternal/precordial pleuritic chest pain -Relieved by sitting forward -May radiate to trapezius ridge/neck/ shoulder

Respiratory:

Pulmonary embolism	-Pleuritic chest pain  -SOB ± haemoptysis -Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
Pneumothorax	-Sudden onset pleuritic chest pain -SOB if large enough -Risk factors, e.g. tall/thin, Marfan syndrome, COPD/asthma

Non-cardiorespiratory:

Gastro-oesophageal reflux disease	-Retrosternal burning chest pain -Related to meals, lying, straining -Water brash
Anxiety/panic attack	-Tight chest pain, SOB, sweating, dizziness, palpitations, feeling of impending doom -Anxious personality and other symptoms of generalised anxiety disorder  -Recurrent episodes triggered by a stimulus (e.g. crowds)
Musculoskeletal	-Sharp chest pain -Exacerbated by movement and inspiration -Can point to where it is worst -Exacerbated by pressure over area

Others:

Other differentials

Costochondritis and Tietze’s syndrome (sharp pleuritic sternal pain with tenderness), Pleurisy (sharp unilateral pleuritic chest pain), Gastritis, Myocarditis

Breathlessness

Exploring symptom

• Timeframe
  • Duration
  • Onset (sudden or gradual)
  • Progression
  • Timing (intermittent or continuous)
• Breathlessness
  • Normal vs. current exercise tolerance (what makes them stop?)
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Diurnal/seasonal variation

Relevant system reviews

• General
  • Fever, sweats
• Cardiorespiratory
  • Chest pain, palpitations, cough, sputum, haemoptysis, leg swelling 

Differential diagnoses and clues

Cardiac:

Myocardial infarction	-Acute onset SOB, often wakes them -Associated nausea/sweatiness -May have crushing central chest pain -Cardiovascular risk factors
Heart failure	-SOB, orthopnoea, paroxysmal nocturnal dyspnoea -Pink frothy sputum if acute LVF -Peripheral oedema -Cardiac history

Respiratory:

LRTI/pneumonia	-Acute SOB, cough and sputum -Systemic symptoms, e.g. fever
Asthma	-Intermittent wheeze -Diurnal variation -Nocturnal cough -Exacerbating factors, e.g. exercise, pets
COPD	-Chronic SOB -Significant smoking history -Chronic sputum production
Pneumothorax	-Sudden onset pleuritic chest pain -Risk factors, e.g. tall/thin, Marfan syndrome, COPD/asthma
Pulmonary embolism	-Pleuritic chest pain  -Haemoptysis -Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
Pulmonary fibrosis	-Progressive SOB over long period -Dry cough

Others:

Other differentials

Anaemia, Hyperventilation in anxiety, Pleural effusion, DKA, Lobar collapse, Bronchiectasis, Aortic stenosis, Neuromuscular causes, Sarcoidosis/TB/extrinsic allergic alveolitis

Cough

Exploring symptom

• Timeframe
  • Duration
  • Progression
  • Timing (intermittent or continuous)
• Cough
  • Productive or non-productive
  • Triggers, nocturnal
• Sputum (if present)
  • How much, how often
  • Colour, consistency
  • Any blood
• Haemoptysis (if present)
  • Volume
  • Fresh or altered blood
  • Frequency
  • Nature of associated sputum. Mixed in?

Relevant system reviews

• General
  • Fever, sweats, weight loss
• Cardiorespiratory
  • Chest pain, palpitations, SOB/wheeze, leg swelling

Differential diagnoses and clues

Respiratory:

URTI/LRTI/ pneumonia	-Acute productive cough -May have associated SOB -Systemic symptoms, e.g. fever
Asthma	-Nocturnal cough -Intermittent wheeze -Diurnal variation -Exacerbating factors, e.g. exercise, pets
Post-nasal drip	-Chronic rhinitis/sinusitis -Chronic cough to clear throat
COPD	-Chronic productive cough  -Chronic SOB -Significant smoking history
Lung tumour	-Haemoptysis -Weight loss -Significant smoking history

Others:

Other differentials

GORD, Smoking, LVF, Drugs (e.g. ACE inhibitor), Bronchiectasis, Interstitial lung disease, Sarcoidosis/TB, Cystic fibrosis

Haemoptysis

Exploring symptom

• Timeframe
  • Duration
  • Progression
  • Timing (intermittent or continuous)
• Cough
  • Productive or non-productive
  • Triggers, nocturnal
• Haemoptysis
  • Volume
  • Fresh or altered blood
  • Frequency
  • Nature of associated sputum. Mixed in?
• Sputum (if present)
  • How much, how often
  • Colour, consistency

Relevant system reviews

• General
  • Fever, sweats, weight loss
• Cardiorespiratory
  • Chest pain, palpitations, SOB/wheeze, leg swelling

Differential diagnoses and clues

Respiratory:

Pneumonia	-Acute productive cough -May have associated SOB -Systemic symptoms, e.g. fever
Pulmonary embolism	-Pleuritic chest pain and SOB -Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
Lung tumour	-Weight loss -Significant smoking history
Bronchiectasis	-Chronic productive cough -Recurrent chest infections -Cause e.g. CF, childhood respiratory illness, TB, immunosuppression

Others:

Other differentials

Prolonged coughing, Pulmonary oedema, Mitral stenosis, TB, Laryngeal carcinoma, Polyarteritis nodosa, Goodpasture’s syndrome, Aspergillosis

Try a question or two

Now it’s your time to shine – here are some practice OSCE stations!

1. Haemoptysis
2. PE
3. Breathlessness
4. Heart failure
5. There’s lots more to do…