Chest pain
Exploring symptom
Pain
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating/relieving factors
Severity
Relevant system reviews
General
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
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)
A patient presents to ED with chest pain and this trace. What would you do?
Interpretation management
Covered in OSCE Stations
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
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!
Haemoptysis
PE
Breathlessness
Heart failure
There’s lots more to do…
Hello
How are ya