Differentiating Chest Symptoms

Differentiating Chest Symptoms

Cough

·        Due to non-specific irritation from pharynx to lungs

·        Note duration:

o   Short Þ Respiratory tract infection (especially if fever)

o   Long Þ asthma, CHF

o   Long + irritating and dry Þ ?reflux and aspiration

o   Long + sputum Þ bronchiectasis

·        Note time of day:

o   Night Þ asthma, heart failure

o   After food Þ reflux

·        Infective respiratory causes:

o   Yellow/green sputum Þ bronchitis, pneumonia

o   Dark, fowl smelling sputum Þ anaerobic abscess

·        Other potential causes:

o   CORD

o   Psychogenic

o   ACE inhibitors

·        Sputum:

o   Yellow or green: lobar pneumonia or bronchiectasis

o   Foul smelling and dark: anaerobic abscess

o   Pink and frothy: not sputum but pulmonary oedema

·        Haemoptysis (coughing blood) can be: bronchitis, cancer, bronchiectasis, cystic fibrosis, abscess, pneumonia, TB, foreign body, Goodpasture‟s syndrome, rupture of a blood vessel after coughing, LV failure or mitral stenosis. Exclude nasal bleeding and haematemesis

Chest Pain

·        Very common reason for A & E attendance: but only a few have S-T elevation MI

·        Very localised pain (i.e. point to it with a finger) unlikely to be ischaemic

·        History taking:

o   Often a lot of denial

o   Key question is time course (acute & on-going, episodic, persistence, etc)

o   What causes it? If exertion, how far can you walk? Worse going up hill or into a cold wind? How long does it take to settle? What do you do to relieved it? Is the pain related to breathlessness

o   Family history: not when did family die but when did it start – if patient young then looking for early onset in family

o   Risk factors: smoking, hypertension, diabetes, hyperlipideamia, obesity, homocsytinaemia, age, sex (women better prior to menopause).

·        Causes:

o   Cardiac:

§  Myocardial ischaemia (narrowing of arteries, acute thrombosis, stenosis ® ↓perfusion pressure, angina pectoralis). Gripping, crushing central chest pain. Pain may radiate. Provoked by exercise, relieved by rest

§  Myocardial infarction

§  Pericarditis (if infectious then severe inflammation, if secondary to MI then more mild. ST elevation on all leads). Pain changes with position/movement, respiration & coughing. Sharp & severe central chest pain

§  Aortic Stenosis

o   Vascular:

§  Aortic aneurysm: central chest pain radiating to the back.  Can mimic MI pain

§  Pulmonary Embolism (PE): very sudden onset of SOB – may ease gradually (as clot disperses). Several days later – pleuretic chest pain, may have high fever, haemoptasis

§  Dissection: brachial pulse in each arm different, very sudden onset of very severe pain (c.f. MI has unstable angina phase first)

o        Right ventricular strain

·        Pulmonary:

o   Pleuritis or Pneumonia

o   Tracheobronchitis

o   Pneumothorax

o   Tumour

o   Emphysema

·        Gastrointestinal:

o   Oesophageal reflux

o   Oesophageal spasm

o   Mallory-Weiss tear

o   Peptic disease (injury to oesophagus, ulcers, pancreatitis, bilary)

o   Biliary disease

o   Pancreatitis: do amylase to exclude

·        Musculoskeletal (will be localised – can point to it, will be palpable tenderness, pain on movement and maybe history of trauma)

o   Cervical disk disease

o   Costochondritis

o   Arthritis of shoulder or spine

o   Intercostal muscle cramps

o   Subacromial bursitis

·        Other:

o   Breast disorders

o   Chest wall tumours

o   Herpes Zoster prior to eruption

o   Psychogenic causes

Breathlessness

·        Normal up to 16 breaths per minute.  20 is definitely high

·        History questions should include:

o  Ask patient what they mean by breathless

o  How much exertion does it take to make them breathless (eg distance walked, stairs climbed)

o  Exclude obesity and lack of fitness 

o   Chest pain: pleuretic is sharp and made worse by coughing and deep inspiration.  Usually localised

o  Occupational triggers: e.g. asbestos, legionella, occupational allergens, hobbies, birds, animals 

o  Onset (slow over yearsÞ ?fibrosis)

o  SOB on raising arms (eg reaching into a cupboard) Þ using accessory muscles to breath

o  Orthopnoea: breathless when lying down

o  Fever at night: consider TB, pneumonia, mesothelioma

o  Sleep apnoea: ask about snoring, daytime somnolence, chronic fatigue

o  Anxiety symptoms

o  Immune status (® PCP or TB) 

o  Medications for clues to condition and for possible side effects, eg PE from OC pill, cough from ACE inhibitors, cocaine 

o  SMOKING

·        Check: cyanosis, can they complete a sentence, peak flow, consciousness level, pulse

·        Divide into:

o  Acute: PE, hyperventilation (tingling, strange pains – alkalotic), acute LVF (no oedema c.f. CHF), pneumothorax, lung collapse due to many causes, pneumonia

o  Chronic: COPD (asthma, bronchitis, emphysema), interstitial lung disease

·        Asthma is fluctuating not progressive (i.e. „Do you have good days and bad days‟)

·        Obstructive: trouble breathing out

·        Restrictive: trouble breathing in 

·        Think of systems: cardiac, respiratory, blood (anaemia, jaundice), hyperthyroidism, psychogenic, acidosis etc

·        Paroxysmal Nocturnal Dyspnoea (PND):

o  Paroxysmal = sudden recurrence or intensification of symptoms

·               Heart failure: wakes feeling like they‟re suffocating, get out of bed and open window, may wheeze

o   (cardiac asthma), may take ½ an hour to settle 

·        Sleep apnoea: wakes feeling like they‟re suffocating, panics, sits up, and settles very quickly. Get collaborative history

·        Asthma: wakes up coughing

Cyanosis

·        Caused by > 50 gm/L of reduced Hb (so if ­Hb concentration and CORD then easy to be cyanosed ® blue bloaters)

·        < 66% saturation at normal HB (ie late sign)

·        < 40% saturation in anaemia

·        Causes:

o   Cardiac: shunts or congenital heart disease

o   Non-cardiac: e.g. hypoxia