Table of Contents
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 |
