Chest Pain Practice Sheet
Table of Contents
Prompt
Mr Jones is a 55-year-old gentleman who is complaining of intermittent right-sided chest pain and shortness of breath.
Please take a history from, and examine Mr Jones.
Presenting Complaint
Mr Jones felt feverish and developed a cough 8 days ago. He has come in today as he has now developed chest pain and shortness of breath and is worried that he may have something serious.
Chest pain
Site: Right side of chest
Onset: Symptoms started roughly 8 days ago; pain started 2 days ago
Character: Sharp pain
Radiation: No radiation
Associated symptoms: Shortness of breath and cough
Timing: Intermittent, pain only present when coughing or taking deep breath
Exacerbating / relieving factors: Pain is worse when breathing in or coughing
Severity of pain: 7/10
Cough
Productive
Green sputum
No haemoptysis
Shortness of breath
Intermittent
- Caused by not being able to take full breath / catching pain in chest
- Worse on exertion
Systems Review
Cardio: No palpitations, no ankle swelling, no PND, no syncope
- Resp: No wheeze, no stridor, current smoker, no asbestos exposure
- GI: Reduced appetite, no vomiting, no epigastric pain, no change in bowel habit
- Infective: Fevers, no coryzal symptoms, no sore throat, no rashes, no dysuria
- Red flags: No weight loss, no lumps or bumps, no night sweats
Past Medical History
PMHx: Hypertension, no previous hospital admissions
- DHx: Amlodopine
- Allergies: NKDA, allergic to cats
- Vaccinations status: Annual flu vaccine
Social History
Smoking: 15-20 cigarettes each day for past 30 years
- Alcohol: Nil
- Illicit drug use: Nil
- Occupation: Social worker, sees a lot of people, uses public transport everyday primarily the bus
- Home: Lives in flat with wife, she is not unwell, no mould or exposures
- FHx: Mother has COPD, Father died from heart attack
ICE
Ideas: Caught a chest infection from someone at work.
- Concerns: Could the chest pain be a heart attack?
- Expectations: Medication to make him feel better so that he can get back to work.
Examination
- End of bed: Increased work of breathing
- General examination: Tar stains on fingers, no peripheral cyanosis, no skin changes, pulse regular, HR 106, BP 108/66, RR 30, Temp 38.6
- Inspection: Even chest expansion, no chest deformities
- Palpation: Trachea central, apex beat not displaced
- Auscultation: HS I + II + 0, course crackles on right side from base to mid zone, no wheeze, no stridor
- Percussion: Slight dullness of right base
- Other: JVP not raised, calves SNT
VIVA Questions
Pneumonia:
Fever and productive cough make an infective cause more likely, unilateral crackles on auscultation are in keeping with pneumonia.
IECOPD:
As above an infective respiratory cause is likely, and the patient has a significant smoking history and FHx.
PE / Influenza / Heart failure / Other:
With appropriate justification.
Bedside:
ECG – To look for cardiac cause such as ischaemia
Flu Swab – Detection of viral cause of symptoms
ABG – Type one respiratory failure, respiratory alkalosis, raised lactate if septic
Laboratory:
FBC – Raised WCC in infection, anaemia could also cause SOB
U&E’s – Urea for calculation of CURB-65 for severity
CRP – Increased in infection
D-dimer – Raised in PE
BNP – Raised in Heart Failure
Blood cultures: For detection of sepsis causing pathogens
Imaging:
Chest XR – Consolidation in pneumonia, pulmonary oedema in heart failure
CTPA – If suspecting PE
Special / Other:
Urinary antigen – For detection of specific pathogens that can cause pneumonia
Sputum MCS – specific pathogens that can cause pneumonia
Demographics:
AP plain film of a 55yr old male. Confirm correct patient.
Image quality:
Not rotated, adequate penetration.
Airway:
Trachea central
Breathing:
Right lower zone consolidation.
Lung markings extend to chest wall, no costophrenic angle blunting.
Cardiac:
No cardiomegaly, no widened mediastinum.
Diaphragm:
Slight elevation of right hemidiaphragm.
No pneumoperitoneum.
The above findings are consistent with a right lower lobe pneumonia.