Share your insights

Help us by sharing what content you've recieved in your exams


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

Myocarditis

  • Fever
  • Palpitations
  • Symptoms of heart failure

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

Other non-cardiorespiratory differentials

  • 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

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

Aortic stenosis

  • Exertional breathlessness/syncope

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 and sputum production
  • Significant smoking history

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

Other respiratory differentials

  • 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

URTI / LRTI / pneumonia

  • Acute productive cough
  • May have associated SOB
  • Systemic symptoms, e.g. fever

Asthma

  • Nocturnal dry 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

Other respiratory differentials

  • Bronchiectasis
  • Interstitial lung disease
  • Sarcoidosis
  • TB
  • Cystic fibrosis

Others

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

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

Lung tumour

  • Weight loss
  • Significant smoking history

Bronchiectasis

  • Chronic productive cough
  • Recurrent chest infections
  • Cause e.g. CF, childhood respiratory illness, TB, immunosuppression

Other respiratory differentials

  • 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?

Oops! This section is restricted to members. Click here to signup!

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

Oops! This section is restricted to members. Click here to signup!

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?

Oops! This section is restricted to members. Click here to signup!

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…

2 Comments

    1. Adam Slonim says:

      How are ya

Leave a Reply