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
- Crushing central chest pain
- Radiates to neck/left arm
- Associated nausea/SOB/sweatiness
- Cardiovascular risk factors
- Cardiac-type chest pain
- Associated with exertion
- Relieved by rest
- Tearing chest pain of very sudden onset
- Radiates to back
- Pain in other sites, e.g. arms, legs, neck, head
- Retrosternal/precordial pleuritic chest pain
- Relieved by sitting forward
- May radiate to trapezius ridge/neck/ shoulder
- Fever
- Palpitations
- Symptoms of heart failure
Respiratory
- Pleuritic chest pain
- SOB ± haemoptysis
- Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
- 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
- Anxiety/panic attack
- Musculoskeletal
- Other non-cardiorespiratory differentials
- Retrosternal burning chest pain
- Related to meals, lying, straining
- Water brash
- 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)
- Sharp chest pain
- Exacerbated by movement and inspiration
- Can point to where it is worst
- Exacerbated by pressure over area
- Costochondritis and Tietze’s syndrome (sharp pleuritic sternal pain with tenderness)
- Pleurisy (sharp unilateral pleuritic chest pain)
- Gastritis
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
- Acute onset SOB, often wakes them
- Associated nausea/sweatiness
- May have crushing central chest pain
- Cardiovascular risk factors
- SOB, orthopnoea, paroxysmal nocturnal dyspnoea
- Pink frothy sputum if acute LVF
- Peripheral oedema
- Cardiac history
- Exertional breathlessness/syncope
Respiratory
- LRTI/pneumonia
- Asthma
- COPD
- Pneumothorax
- Pulmonary embolism
- Pulmonary fibrosis
- Other respiratory differentials
- Acute SOB, cough and sputum
- Systemic symptoms, e.g. fever
- Intermittent wheeze
- Diurnal variation
- Nocturnal cough
- Exacerbating factors, e.g. exercise, pets
- Chronic SOB and sputum production
- Significant smoking history
- Sudden onset pleuritic chest pain
- Risk factors, e.g. tall/thin, Marfan syndrome, COPD/asthma
- Pleuritic chest pain
- Haemoptysis
- Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
- Progressive SOB over long period
- Dry cough
- Pleural effusion
- Lobar collapse
- Bronchiectasis
- Sarcoidosis
- TB
- Extrinsic allergic alveolitis
Others
- Anaemia
- Hyperventilation in anxiety
- Metabolic acidosis compensation, e.g. in DKA
- Neuromuscular causes
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
- Acute productive cough
- May have associated SOB
- Systemic symptoms, e.g. fever
- Nocturnal dry cough
- Intermittent wheeze
- Diurnal variation
- Exacerbating factors, e.g. exercise, pets
- Chronic rhinitis/sinusitis
- Chronic cough to clear throat
- Chronic productive cough
- Chronic SOB
- Significant smoking history
- Haemoptysis
- Weight loss
- Significant smoking history
- Bronchiectasis
- Interstitial lung disease
- Sarcoidosis
- TB
- Cystic fibrosis
Others
- GORD
- Smoking
- LVF
- Drugs (e.g. ACE inhibitors)
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
- Acute productive cough
- May have associated SOB
- Systemic symptoms, e.g. fever
- Pleuritic chest pain and SOB
- Risk factors (e.g. long haul flight, recent surgery, immobility, malignancy)
- Weight loss
- Significant smoking history
- Chronic productive cough
- Recurrent chest infections
- Cause e.g. CF, childhood respiratory illness, TB, immunosuppression
- TB
- Aspergillosis
Others
- Prolonged coughing
- Pulmonary oedema
- Mitral stenosis
- Laryngeal carcinoma
- Polyarteritis nodosa
- Goodpasture’s syndrome
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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