Chest Discomfort, Night Cough and Easy Bruising — The Important Questions a Doctor Should Ask.

Introduction

There is an enormous amount of patients that present to the clinic with either respiratory and/or cardiovascular symptoms (not as much with the haematology system). A skilful physician will be able to expertly ask the right questions that have a tremendous amount of significance in finding out the current problems. Hence, asking the right questions is extremely important in medicine.

Cardiovascular System

Imagine a patient arrives with a sore chest, what should be investigated, and what should be asked?

1) Can you describe your chest discomfort?

Discomfort: noun - slight pain. To thoroughly understand the description of pain will navigate the diagnoses.

Quality of pain: a typical older patient may deny the feeling of chest pain caused by myocardial ischemia and may delay seeking treatment where timing is essential in management; the typical feeling could be: 

• Burning ‐ Infarction pain is often mistaken for heartburn or indigestion, especially in women

• Chest Constriction ‐ The ‘Levine sign’ is displayed by a patient suffering from chest pain caused by a myocardial infarction

• Pressure, squeezing, tightness

Chest discomfort provoked by exertion is a classic symptom of angina, although oesophageal pain can also result from exertion.

Pain made worse by swallowing is likely of oesophageal origin. Pain that responds to sublingual nitro-glycerine or cessation of activity strongly suggests a cardiac ischemic aetiology, while pericarditis pain typically improves with sitting up and leaning forward. The severity of pain does not necessarily correlate with the degree of ischemia. As many as 1/3 of myocardial infarctions may go undetected by the patient.

Pain that localises to a small area of the chest is more likely to be related to a chest wall or pleural origin rather than the heart. Ischemic cardiac pain is a diffuse type of non-localised pain. The pain of myocardial ischemia often radiates to the neck, throat, lower jaw, teeth, upper extremities, or shoulder. If the chest pain is radiating to several areas, there is an increased chance that the patient is having a myocardial infarction (MI).

2) When did this discomfort start?

Having a full description of the onset, such as the time the pain started, rhythm and cycle time, the time of sudden, prolonged or pattern like pain can relate to certain cardiovascular diseases. Knowing the onset of chest pain is vital to help determine the cause and treatment of the pain. Ischemic pain is most often gradual with increasing intensity over time. A crescendo (intensity) pattern of pain can also be caused by oesophageal disease. Pain associated with pneumothorax, aortic dissection, or acute pulmonary embolism typically has an abrupt onset with the initial sensation being the most intense.

Understanding the duration of pain and any patterns are also helpful. The pain from myocardial ischemia generally lasts for a few minutes, whereas the pain from a myocardial infarction may be more prolonged. Chest discomfort that only lasts for a few seconds or pain that is constant for days or weeks is not generally due to ischemia. Myocardial ischemia may have a circadian pattern. It is more likely to occur in the morning than in the afternoon, correlating with an increase in sympathetic tone. However, this pattern may not be exhibited in patients with diabetes or patients taking beta‐blockers as the patient’s sympathetic tone is altered.

3) Could you describe your past health history in detail?

The purpose of cardiovascular health history is to provide information about the patient’s cardiovascular symptoms and how they developed. Thoroughly assessing past health history will allow the understanding of the possible damage caused on the heart. That is on the myocardial wall, valves, chronically under stress (as a whole organ), tissue perfusion damage, smoking, diet, overweight and physical inactivity.

• Past infections that went unnoticed - rheumatic fever causes damage to heart valves

• Congestive heart failure – causes hypertrophy or weakening of the myocardial wall

• Congenital heart disease – abnormalities could be the cause of the discomfort

• Previous heart surgeries – especially in the elderly

Co-morbidities affecting the hearts such as:

• Hypertension – chronic stress on the heart

• Diabetes, hypothyroidism, dyslipidaemia, elevated blood cholesterol/triglycerides – increases the risk of myocardial ischemia, MI

• Previous history of stroke

• Certain cancer and their medication 

• Reoccurrence of chest pain (misdiagnosed myocardial infarction)

Finding out previous heart disease, when and how it was treated, last EKG, stress tests, and serum cholesterol levels will help in the probability of diagnosing the right cardiovascular disease.

4) Are there any other symptoms that you have noticed?

Finding symptoms can help in eliminating or reinforce the probability of the right diagnosis. Ultimately the cardinal signs should be found to be sure of the diagnosis as non-cardiac chest pain can mislead diagnosis. All these conditions may cause different chest discomfort (sharp, broad, radiating) and may mislead to a cardiovascular diagnosis.

Misleading condition with shared symptoms:

Digestive causes:

• Gastroesophageal reflux disease

• Stomach ulcers

• Visceral or oesophageal hypersensitivity

• Gall bladder, pancreas problems – pain radiates to the chest

Finding symptoms such as heartburn or a bitter taste in the mouth due to stomach fluid coming up, coughing up blood, can make a cardiovascular disease unlikely. Gall stones: look out for jaundice and pain in the right shoulder.

Lung disorders causing chest pain:

• Pulmonary embolism – sudden difficulty breathing

• Pneumonia – fever, chills, or coughing

• Pleurisy, collapsed lung – pain worsens when moving

These symptoms make cardiovascular disease unlikely.

Muscle, inflammation and bone causes:

Some types of chest pain are associated with injuries and other problems affecting the structures that make up the chest wall, including:

• Costochondritis – often mistaken for a heart attack. Look for trauma symptoms especially falls in the elderly

• Pericarditis – lookout for virus symptoms, medication uses, radiotherapy

• Injured ribs

Look for movement pain and trauma and assess the movement of the patient. 

Respiratory System

A patient presents coughing, what should be investigated, and what should be asked?

1) Are there any other symptoms that you have noticed?

Thoroughly lookout for other symptoms such as fatigue, loss of appetite, copious sputum production, coughing up blood, wheezing and shortness of breath.

The cardinal signs of cough should be night sweats, loss of weight and prolonged fever. These should be diagnosed and found as they have severe consequences. A prolonged fever demonstrates immunocompromised immunity and prolonged and/or hidden infections. Unexplained weight loss demonstrates an endocrine disorder or an uncontrollable high energy mitosis division. Night sweats demonstrate an endocrine imbalance and a severe infection due to fever or the disease itself.

• Tuberculosis – an infection in the lung causes excessive cough, night sweats, weight loss

• HIV – other causing infections due to AIDS where pneumonia and latent TB takes over. Symptoms such as night sweats, loss of weight and fever

• Hyperthyroidism – thyroid nodules irritates the trachea or the vocal cord nerve

Lung cancer - Most lung cancers do not cause symptoms until the disease has advanced, in part because the lungs have few nerve endings.

2) Is your cough persistent?

Dividing the potential diagnose from acute/once-off and chronic/persistent/nagging causing coughs. A persistence cough is most likely coming from these conditions. For a non-smoker, the first three (either singly or in combination) account for nearly all chronic coughs.

Common causes of persistent cough:

• Postnasal drip – patients cough more at night and are often aware of a tickling feeling at the back of their throats either from an infection or mucus

• Asthma – cough variant asthma produces a persistent, dry cough that occurs and may begin at night

• Gastroesophageal reflux disease – acid content goes upstream, irritates nerves in the lower oesophagus, and these nerves can trigger the cough reflex even without the distress signal of pain

• Chronic bronchitis; bronchiectasis

• Treatment with ACE inhibitors - occurs in up to 20%

Less common causes of persistent cough:

• Airborne environmental irritants

• Aspiration during swallowing

• Heart failure

• Lung infections

• Pertussis (whooping cough)

• Lung cancer

When identifying a persistent cough, the practitioner can then further investigate the cause of the persistent cough.

3) When coughing, do you cough-up any materials or substances?

Observation sputum can reveal crucial clinical information concerning the type and level of the inflammatory process, the physical properties of the material, the extent of bronchial mucosal damage, and the identification of pathogenic microorganisms that may be present. A dry or wet cough can help when choosing a medication course such as when to choose an antitussive or mucolytic if sputum is present and in diagnosing the current condition.

Most common dry cough:

• Asthma

• Gastro-oesophageal reflux

• Whooping cough (affects upper airways)

• Smoking without infections

• Post-natal drip

• ACE inhibitors

Thoroughly look at the colour, smell, clumping and type of mucus:

• Purulent – Thick, yellow/green sputum -> Infectious – pneumonia, bronchiectasis, cystic fibrosis, sinusitis and abscess

• Mucoid – Clear, grey/white -> Chronic obstructive pulmonary disease and asthma

• Serous – Clear, frothy, pink -> Pulmonary oedema, pneumonia, lung cancer, lung abscess, tuberculosis and congestive heart failure

• Blood – Red and bloody -> Malignancy, pulmonary embolus, clotting disorders, infection

These should help and guide the physician. However, disease state cross over and should not be disregarded just on colour, smell and clumping.

4) When lying down, do you cough?

When lying down, patients may experience dyspnea, chest tightness, wheezing, cough, and there is an increase in compacted lung cavity due to gravity while in the supine position. This is aggravated if the patient is obese, have co-morbidities such as hypertension, diabetes, dyslipidaemia and others as well as other factors such as smoking, alcohol, genetics, congenital deformation. Some nerves may get triggered and induce coughing due to build-up of fluids and obstructions such as mucus in the respiratory system.

Common causes when lying in supine position: 

• Gastroesophageal reflux disease – acid content goes upstream, irritates nerves in the lower oesophagus, and these nerves can trigger the cough reflex even

• Congestive heart failure from pulmonary oedema – fluids accumulating in air sacs which induces coughing

• Renal disease – causes pulmonary oedema

• Persistent COPD – builds up of mucus blocks airways, lying down exacerbates the airflow and patency

• Late-stage pregnancy – decreases lung cavity

• Nocturnal asthma

• Allergies

Haematology System

A patient shows that he has a bruise on his left forearm and finds it strange and abnormal, what should be investigated, and what should be asked?

1) Have you noticed any unusual bruising?

Consider nutritional deficiencies, age-related bruising, purpura simplex, medication, and trauma in patients with a first episode of bruising. Thoroughly screen and note for bruising and describe its colours, size, location (superficial/deep), number, if petechiae and/or ecchymoses are present, and type of bruising. This would help indicate and identify the pathology and guide the physician to the right diagnosis. Vitamin K deficiency is shared amongst the population and that bruising increases with age. Two bleeding scores have been proposed where one is used for diagnosis (scored from 0/no symptom to 3/most severe) and the other for descriptive purposes. Lab test such as aPPT, PT and full blood count for haemoglobin, platelets, WBC, would further identify the cause. Genetic testing for certain phenotype may be done.

Bleeding type:

• Ecchymosis – flat and superficial

• Hematoma – may be with swollen, raised, or painful. Generally associated with injury or impact to the skin

Common cause of bruising:

• Vitamin K and vitamin C deficiency

• Senile purpura

• Von Willebrand disease

• Medication

• Thrombocytopenia state

• Leukaemia

• Vasculitis

Rare

• Haemophilia and other coagulating factors

• Endocrine disorders such as Cushing’s disease and Marfan’s syndrome

2) Do you have any family history of bleeding disorders? 

A positive family history increases the risk of a bleeding disorder; family history should be obtained in patients with a suspected bleeding disorder. Easy bruising is unlikely to be a bleeding disorder in patients without a family history of haematology defects. A distinctive bleeding history is a prerequisite for the diagnosis of any bleeding disorder and should guide further laboratory investigations. Taking a personal history starts with a list of screening questions based on a bleeding score system. This bleeding score system is a clinical decision rule to screen for von Willebrand's disease, the most common inherited bleeding disorder. This disease results from a quantitative or qualitative defect in von Willebrand's factor, which is required for platelet aggregation. A history of bleeding that requires surgical intervention, blood transfusion, or replacement therapy is a significant red flag for a bleeding disorder, therefore, receives a high number of points.

Inherited haematology disease:

• Von Willebrand

• Haemophilia

• Sickle cell

• Thalassaemia

3) Have you been eating correctly such of what a dietician would recommend?

(correctly to them may be completely different to someone else – hence the standardization).

Identifying the diet thoroughly to pinpoint if there are any deficiencies of mineral, fats, proteins, carbohydrates and vitamins (K, D, C). Vitamin K is required for the complete synthesis of specific proteins that are prerequisites for blood coagulation. Vitamin C is required to build healthy collagen and can result in bleeding disorders. Vitamin D is essential for bone calcium homeostasis and bone mineralization and is typically lowered in patients with haematological disease. Essential minerals such as zinc, calcium, potassium and magnesium may not be absorbed sufficiently. In an ageing patient, malnutrition is common and is typically seen when they live alone or in a nursing home. They also have fragile organs such as thinning of the skin and slower healing.

Patients with a fitting denture, chronic pain and inflammation in the mouth such as gingivitis or toothache may be malnourished. Patients with inflammatory bowels disease such as Crohn’s disease and ulcerative colitis will lose weight and not absorb the right nutrients. Malnutrition could suggest cancer and have haematological effects on a patient. Anaemia in the elderly population has a high incidence and is related to increased mortality risk. There is a caloric and protein restriction, iron, vitamin B12, folic deficiency are the causes of nutritional anaemia. Protein and energy malnutrition stimulate an increased cytokines production with the induction of inflammation, immunodeficiency and anaemia.

4) Are you on any medication?

There is a higher risk of elderly patients to be on medication that would restrict clot formation or aggregation/adherence of platelets. Patients who are 50 years old and above have an increased risk of chronic disease and co-morbidities, which includes hypertension, obesity, dyslipidaemia, diabetes, hypercholesterolemia and hypertriglyceridemia are key factors. The risk of having a stroke more than doubles each decade after the age of 55. It is expected to see heparin and warfarin in patients as early as 50 years old. The U.S. Preventive Services Task Force recommends daily aspirin therapy if you are age 50 to 59 and must follow a strict guideline. Most commonly, 81 mg — can be effective. However, some medication if taken in overdose or missed managed, will cause unnecessary bleeding. Revaluation and changing drug treatment or decrease and adjusting dosing should be recommended.

Medications that cause bleeding and bruising:

Common

• Aspirin

• Clopidogrel (Plavix)

• Heparin

• Nonsteroidal anti-inflammatory drugs

• Corticosteroids

• Warfarin (Coumadin)

Rare

• Cephalosporins

• Penicillins

• Selective serotonin reuptake inhibitors

• Tricyclic antidepressants

• Testosterone replacement

Published 30th July 2019. Last reviewed 30th December 2021.

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