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

  • 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

  • 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

  • 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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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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