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Common chest histories

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 differentialsCostochondritis 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 differentialsAnaemia, 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 differentialsGORD, 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 differentialsProlonged coughing, Pulmonary oedema, Mitral stenosis, TB, Laryngeal carcinoma, Polyarteritis nodosa, Goodpasture’s syndrome, Aspergillosis 

Try a question or two

A patient presents with sharp chest pain, worse on movement and inspiration. Which systems review questions would you ask, and which conditions would those symptoms make you worry about?

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Which investigations would you consider in this patient, and why?

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The patient’s chest x-ray and ECG are normal. His bloods are normal other than a raised D-dimer. What would you do next?

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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…
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