CHEST PAIN

Non-central
1. Pleural
Infection: pneumonia,
Central
bronchiectasis, tuberculosis
1.Malignancy:
Tracheal lung cancer,
mesothelioma,
Infection metastatic
Irritant dusts
Pneumothorax
2.Pulmonary
Cardiac infarction
Massive pulmonary
Connective tissue disease:
rheumatoid
thromboembolism
arthritis, SLE
Acute
2. Chestmyocardial
wall infarction/
ischaemia
Malignancy: lung cancer,
3. Oesophagealbony
mesothelioma,
metastases
Oesophagitis
Rupture cough/
Persistent
breathlessness
4. Great vessels
Aortic dissection
Muscle sprains/tears
5.Bornholms
Mediastinaldisease
Lung cancer
(Coxsackie B infection)
Tietzes
Thymoma syndrome
Lymphadenopathy
(costochondritis)
Rib
Metastases
fracture
Mediastinitis
Intercostal nerve
compression
Thoracic shingles (herpes
zoster)
Chest pain can originate from the parietal pleura, the
chest wall and mediastinal structures. The lungs do not cause pain because their innervation is
exclusively autonomic. Pleural pain is sharp, stabbing and intensifed by inspiration or coughing.
Irritation of the parietal pleura of the upper six ribs causes localised pain. Irritation of the parietal pleura
overlying the central diaphragm innervated by the phrenic nerve is referred to the neck or shoulder tip.
The lower six intercostal nerves innervate the parietal pleura of the lower ribs and the outer diaphragm,
and pain from these sites may be referred to
the upper abdomen. Common causes of pleuritic chest pain are pulmonary embolism, pneumonia,
pneumothorax and fractured ribs. Chest wall pain which is sudden and localised after vigorous coughing
or direct trauma is characteristic of rib fractures or intercostal muscle injury. Prevesicular herpes zoster
and intercostal nerve root compression can cause chest pain in a thoracic dermatomal distribution.
Chest wall pain due to direct invasion by lung cancer, mesothelioma or rib metastasis is typically dull,
aching or gnawing, unrelated to respiration, progressively worsens and disrupts sleep. Pancoasts
tumour of the lung apex may involve the first rib and the brachial plexus, causing referred pain down the
medial side of the ipsilateral arm. Mediastinal pain is central, retrosternal and unrelated
to respiration or cough. Irritant dusts or infection of the tracheobronchial tree produce a raw, burning
retrosternal pain worse on coughing. A dull, aching retrosternal pain that disturbs sleep is a feature of
cancer invading mediastinal lymph nodes or an enlarging thymoma. Massive pulmonary
thromboembolism acutely increasing right ventricular pressure may produce central chest pain similar to
myocardial ischaemia.
SHORTNESS OF BREATH

1. Non-cardiorespiratory
Anaemia
Metabolic acidosis
Obesity
Psychogenic
Neurogenic

2. Cardiac
Left ventricular failure
Mitral valve disease
Cardiomyopathy
Constrictive pericarditis
Pericardial effusion

3. Respiratory Airways
Laryngeal tumour
Foreign body
Asthma
COPD
Bronchiectasis
Lung cancer
Bronchiolitis
Cystic fibrosis
Parenchyma
Pulmonary fibrosis
Alveolitis
Sarcoidosis
Tuberculosis
Pneumonia
Diffuse infections, e.g.
Pneumocystis jiroveci pneumonia
Tumour (metastatic, lymphangitis)
Pulmonary circulation
Pulmonary thromboembolism
Pulmonary vasculitis
Primary pulmonary hypertension
Pleural
Pneumothorax
Effusion
Diffuse pleural fibrosis
Chest wall
Kyphoscoliosis
Ankylosing spondylitis
Neuromuscular
 Myasthenia gravis
Neuropathies
Muscular dystrophies
GuillainBarr syndrome

Minutes
Pulmonary thromboembolism
Pneumothorax
Asthma
Inhaled foreign body
Acute left ventricular failure

Hours to days
Pneumonia
Asthma
Exacerbation of COPD

Weeks to months
Anaemia
Pleural effusion
Respiratory neuromuscular
disorders
Months to years
COPD
Pulmonary fibrosis
Pulmonary tuberculosis

Grade 1
Breathless when hurrying on the level or
walking up a slight hill
Grade 2
Breathlessness when walking with people of
own age or on level ground
Grade 3
Walks slower than peers, or stops when
walking on the at at own pace
Grade 4
Stops after walking 100 metres, or a few
minutes, on the level
Grade 5
Too breathless to leave the house
(Grade 5b)
Too breathless to wash or dress

Breathlessness when lying at (orthopnoea) is usually associated with left ventricular failure. It can also
be a feature of respiratory muscle weakness, large pleural effusion, massive ascites, morbid obesity or
any severe lung disease. Breathlessness on sitting up (platypnoea) with relief on lying down is rare and
due to right-to-left shunting through a patent foramen ovale, atrial septal defect or a large
intrapulmonary shunt. Breathlessness when lying on one side (trepopnoea) is due to unilateral lung
disease (patient prefers the healthy lung down), dilated cardiomyopathy (patient prefers right side
down) or tumours compressing central airways and major blood vessels. Breathlessness that wakes the
patient from sleep is typical of asthma and left ventricular failure (paroxysmal nocturnal dyspnoea).
Patients with asthma typically wake between 3 and 5 a.m. and have associated wheezing. Breathlessness
worse on waking is more typical of COPD and may improve after coughing up sputum.
Patients with exercise-induced asthma may notice that the breathlessness continues to worsen for 510
minutes after stopping activity. If you suspect asthma, ask about exposure to allergens, smoke,
perfumes, fumes, cold air or drugs, e.g. aspirin, non-steroidal anti-inammatory drugs. Common
allergens are house dust mite (shaking bedding, hoovering), animals (cats, dogs, horses) and grass
pollens (mowing the lawn, the hayfever season) and tree pollens. Breathlessness improving at
weekends or holidays suggests occupational asthma. Ask about symptoms that accompany the
breathlessness, e.g. chest pain, cough, wheeze.

COUGH

Red flag symptoms

Haemoptysis
Breathlessness
Fever
Chest pain
Weight loss

Normal chest X-ray Abnormal chest X-ray

Acute cough
(<3 weeks)
Viral respiratory tract Pneumonia
infection Inhaled foreign body
Bacterial infection Acute hypersensitivity
(acute bronchitis) pneumonitis
Inhaled foreign body
Inhalation of irritant
dusts/fumes

Chronic cough
(>8 weeks)
Gastro-oesophageal Lung tumor
reux disease Tuberculosis
Asthma Interstitial lung disease
Postviral bronchial Bronchiectasis
hyperreactivity
Rhinitis/sinusitis
Cigarette smoking
Drugs, especially
angiotensin-converting
enzyme inhibitors
Irritant dusts/fumes

Cough is a characteristic sound caused by a forced expulsion against an initially closed glottis. Acute
cough is one lasting less than 3 weeks; chronic cough lasts more than 8 weeks. The most common cause
of acute cough is acute upper respiratory tract viral infection. Acute cough is usually self-limiting and
benign, but may occur in more serious conditions. Chronic cough in a non-smoker with a normal chest
X-ray is usually caused by gastro-oesophageal reflux disease, chronic sinus disease with postnasal drip
or angiotensin-converting enzyme inhibitors. Severe asthma or chronic obstructive pulmonary disease
(COPD) causes prolonged wheezy cough and often a paroxysmal dry cough after a viral infection that
lasts several months (bronchial hyperreactivity). A feeble non-explosive bovine cough with hoarseness
suggests lung cancer invading the left recurrent laryngeal nerve causing left vocal cord paralysis, but
may also occur with respiratory muscle weakness due to neuromuscular disorders. Laryngeal
inflammation, infection or tumour causes harsh, barking or painful coughs and associated hoarseness
and the rasping or croaking inspiratory sound of stridor. A moist cough suggests secretions in the
upper and larger airways from bronchial infection and bronchiectasis. A persistent moist smokers
cough first thing in the morning is typical of chronic bronchitis. Smokers often consider this normal but
any change in this cough may indicate lung cancer. Tracheitis and pneumonia cause dry, centrally
painful and nonproductive cough. Chronic dry cough occurs in interstitial lung disease, e.g. idiopathic
pulmonary fibrosis (formerly fibrosing alveolitis).

TYPES OF SPUTUM
Type Appearance Cause
Serous Clear, watery Acute pulmonary oedema
Frothy, pink Alveolar cell cancer
Mucoid Clear, grey Chronic bronchitis/chronic
obstructive pulmonary disease
White, viscid Asthma
Purulent Yellow Acute bronchopulmonary infection
Asthma (eosinophils)
Green Longer-standing infection
Pneumonia
Bronchiectasis
Cystic fibrosis
Lung abscess
Rusty Rusty red Pneumococcal pneumonia

HAEMOPTYSIS

Tumour
Malignant Benign
Lung cancer Bronchial carcinoid
Endobronchial metastases
Infection
Bronchiectasis Mycetoma
 Tuberculosis Cystic fibrosis
Lung abscess
Vascular
Pulmonary infarction Arteriovenous malformation
Vasculitis Goodpastures syndrome
Polyangiitis Iatrogenic
Trauma Bronchoscopic biopsy
Inhaled foreign body Transthoracic lung biopsy
Chest trauma Bronchoscopic diathermy
Cardiac Acute left ventricular failure
Mitral valve disease Anticoagulation
Haematological
Blood dyscrasias

Blood-streaked clear sputum or clots in sputum for more than a week suggest lung cancer. Haemoptysis
with purulent sputum suggests infection. Coughing up large amounts of pure blood is rare but
potentially life threatening; causes include lung cancer, bronchiectasis and tuberculosis and, less
commonly, lung abscess, mycetoma, cystic fibrosis, aortobronchial fistula and granulomatosis with
polyangiitis (formerly Wegeners granulomatosis). Bronchiectasis causes intermittent haemoptysis
associated with copious purulent sputum over years. Daily haemoptysis for a week or more is a
symptom of lung cancer; other causes include tuberculosis and lung abscess. Single episodes of
haemoptysis, if associated with symptoms, e.g. pleuritic chest pain and breathlessness, suggest
pulmonary thromboembolism and infarction and need immediate investigation

ABDOMINAL PAIN

Disorder and Clinical features

Myocardial infarction
Epigastric pain without tenderness,
Angor animi (feeling of impending
death), hypotension, cardiac arrhythmias
Dissecting aortic aneurysm
Tearing interscapular pain
Angor animi, hypotension
Asymmetry of femoral pulses
Acute vertebral collapse
Lateralised pain restricting movement
Tenderness overlying the involved
vertebra
Cord compression
Pain on percussion of thoracic spine
Hyperaesthesia in dermatomal
distribution
Spinal cord signs
Pleurisy
Lateralised pain on coughing
Chest signs, e.g. pleural rub
Herpes zoster
Hyperaesthesia in dermatomal distribution
Vesicular eruption
Diabetic ketoacidosis
Cramp-like pain, vomiting, air hunger
Tachycardia, ketotic breath
Salpingitis or tubal pregnancy
Suprapubic and iliac fossa pain,
localised tenderness, nausea,
vomiting, fever
Torsion of the testis/ovary
Lower abdominal pain
Nausea, vomiting, localised tenderness

Peptic ulcer, Biliary Colic, Renal colic, Acute pancreatitis

VOMITING

Nausea is the sensation of feeling sick. Vomiting is the expulsion of gastric contents via the mouth.
Both are associated with pallor, sweating and hyperventilation. Nausea and vomiting, particularly with
abdominal pain or discomfort, suggest upper gastrointestinal disorders. Remember to consider non-
gastrointestinal causes of nausea and vomiting, especially adverse drug effects, pregnancy and
vestibular disorders. Dyspepsia causes nausea without vomiting. Peptic ulcers seldom cause painless
vomiting unless complicated by pyloric stenosis. Gastric outlet obstruction causes projectile vomiting of
large volumes of gastric content that is not bile-stained (green). Obstruction distal to the pylorus
produces bile-stained vomit. The more distal the level of intestinal obstruction, the more marked the
accompanying symptoms of abdominal distension and intestinal colic. Vomiting is common in
gastroenteritis, cholecystitis, pancreatitis and hepatitis. Vomiting is typically preceded by nausea, but in
raised intracranial pressure may occur without warning. Severe pain may cause it, e.g. renal or biliary
colic, myocardial infarction, as well as systemic disease, metabolic disorders and drug therapy.
Anorexia nervosa and bulimia are eating disorders characterised by undisclosed, self-induced vomiting.
In bulimia, weight is maintained or increased, unlike in anorexia nervosa, where weight loss is obvious.
What medications has the patient been taking?
Is vomiting:
heralded by nausea or occurring without warning?
associated with dyspepsia or abdominal pain?
relieving dyspepsia or abdominal pain?
related to mealtimes, early morning or late evening?
bile-stained, blood-stained or faeculent?

Neurological
Raised intracranial
pressure, e.g. meningitis, brain tumour
Labyrinthitis and Mnires disease
Migraine
 Vasovagal syncope, shock, fear and severe
pain, e.g. renal colic, myocardial infarction
Drugs
Alcohol, opioids, theophyllines, digoxin,
cytotoxic agents, antidepressants
Consider any drug
Metabolic/endocrine
Pregnancy
Diabetic ketoacidosis
Renal failure
Liver failure
Hypercalcaemia
Addisons disease
Psychological
Anorexia nervosa
Bulimia

DIARRHOEA

Acute
Infective gastroenteritis, e.g.
Clostridium diffcile
Drugs (especially antibiotics)
Chronic (>4 weeks)
Irritable bowel syndrome
Inammatory bowel disease
Parasitic infestations, e.g. Giardia lamblia,
amoebiasis, Cryptosporidium spp.
Colorectal cancer
Autonomic neuropathy (especially diabetic)
Laxative abuse and other drug therapies
Hyperthyroidism
Constipation and faecal
impaction(overow)
Small-bowel or right colonic resection
Malabsorption, e.g. lactose defciency,
coeliac disease

Is diarrhoea acute, chronic or intermittent?

Is there tenesmus, urgency or incontinence?
Is the stool:
watery, unformed or semisolid?
Large-volume and not excessively frequent, suggesting small-bowel disease?
Small-volume and excessively frequent, suggesting large-bowel disease?
associated with blood, mucus or pus?
Is sleep disturbed by diarrhoea, suggesting organic disease?
 Is there a history of:
contact with diarrhoea or of travel abroad?
Relevant sexual contact (gay bowel syndrome, human immunodefciency virus (HIV))?
Alcohol abuse or relevant drug therapy?
Gastrointestinal surgery, gastrointestinal disease or inammatory bowel disease?
Family history of gastrointestinal disorder, e.g. gluten enteropathy, Crohns?
Any other gastrointestinal symptom, e.g. abdominal pain and vomiting?
Systemic disease suggested by other symptoms, e.g. rigors or arthralgia?

JAUNDICE
Jaundice is a yellowish discoloration of the skin, sclerae and mucous membranes due to
hyperbilirubinaemia. There is no absolute level at which jaundice is clinically detected but, in good light,
most clinicians will recognise jaundice when bilirubin levels exceed 50 mol/l.
Increased bilirubin production
Haemolysis (unconjugated
hyperbilirubinaemia)
Impaired bilirubin excretion
Congenital
Gilberts syndrome
(unconjugated)
Hepatocellular
Viral hepatitis
Cirrhosis
Drugs
Autoimmune hepatitis
Intrahepatic cholestasis
Drugs
Primary biliary cirrhosis
Extrahepatic cholestasis
Gallstones
Cancer: pancreas, cholangiocarcinoma

Appetite and weight change

Abdominal pain, altered bowel habit
Gastrointestinal bleeding
Pruritus, dark urine, rigors
Drug and alcohol history
Past medical history (pancreatitis, biliary surgery)
Previous jaundice or hepatitis
Blood transfusions (hepatitis B or C)
Family history, e.g. congenital spherocytosis, haemochromatosis
Sexual and contact history (hepatitis B or C)
Travel history and immunisations (hepatitis A)
Skin tattooing (hepatitis B or C)

HAEMATEMESIS
Haematemesis is vomiting blood, which can be fresh and red, or degraded by gastric pepsin, when it is
dark brown in colour and resembles coffee grounds. If the source of bleeding is above the
gastrooesophageal sphincter, e.g. from oesophageal varices, fresh blood may well up in the mouth, as
well as being actively vomited. With a lower oesophageal mucosal tear due to the trauma of forceful
retching (Mallory Weiss syndrome), the patient vomits forcefully several times and fresh blood only
appears after the patient has vomited several times.

Is there a previous history of dyspepsia, peptic ulceration, gastrointestinal bleeding or liver disease?
Is there a history of alcohol, NSAIDs or corticosteroid ingestion?
Did the vomitus comprise fresh blood or coffee ground stained uid?
Was the haematemesis preceded by intense retching?
Was blood staining of the vomitus apparent in the first vomit?

RECTAL BLEEDING CAUSES

Haemorrhoids
Anal fissure
Colorectal polyps
Colorectal cancer
Inammatory bowel disease
Ischaemic colitis
Complicated diverticular disease
Vascular malformation

HEADACHE
Headache is the most common neurological symptom and may be either primary or secondary to other
pathology. The most common causes of headache are migraine and tension-type headache.

Primary
Migraine
Tension-type headache
Trigeminal autonomic cephalalgias (including
cluster headache)
Primary stabbing, cough, exertional or sex
headaches
Primary thunderclap headache
New daily persistent headache
Secondary (symptomatic) to:
Head or neck trauma
Head or neck vascular disease, e.g.
subarachnoid haemorrhage,
vertebral artery dissection, temporal arteritis
Non-vascular intracranial disease
Recreational drug use
Medication overuse e.g. analgesia
Infection
Non-traumatic disorders of head, neck, eyes,
ears, nose, teeth,
mouth, sinuses
Cranial neuralgias, e.g. trigeminal neuralgia
Onset and causes
Acute single
episode
(thunderclap)
Subarachnoid haemorrhage
Idiopathic intracranial hypotension
Cerebral vein thrombosis
Acute meningitis, encephalitis
Acute recurrent
Migraine
Tension-type headache
Cluster headache
Subacute
progressive
Raised intracranial pressure (tumour,
abscess, hydrocephalus, idiopathic
intracranial hypertension)
Infections (meningitis, encephalitis)
Temporal arteritis
Chronic
Chronic daily headache syndrome
Chronic migraine
Medication overuse headache
Cervicogenic headache
Drugs, e.g. nitrates, dipyridamole

LEG WEAKNESS

Weakness suggests joint, neurological or muscle disease. The problem may be focal or generalised.
Weakness due to joint disorders is either from pain inhibiting function or to disruption of the joint or its
supporting structures. Always consider nerve entrapment as a cause, e.g. carpal tunnel syndrome at the
wrist and leg weakness due to spinal root compression caused by a prolapsed intervertebral disc
or spinal stenosis. Muscle disorders can produce widespread weakness associated with pain and fatigue,
e.g. in polymyositis and with a rash in dermatomyositis. Proximal muscle weakness can occur in
endocrine disorders, e.g. hypothyroidism