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92 Chapter 3: Respiratory system

Respiratory chest pain with abdominal pain, e.g. basal pneumonia causing up-
per abdominal pain.
Chest pain can arise from the cardiovascular system, the
respiratory system, the oesophagus or the musculoskele-
talsystem.Respiratorychestpainisusuallyverydifferent Signs
fromischaemicchestpain,asitischaracteristicallysharp,
and worse on inspiration. Clubbing
On enquiring about chest pain ask about the site,
nature (sharp, burning, tearing), radiation, precipitat- Clubbing is an increased amount of soft tissue in the
ing/relieving factors (deep inspiration, coughing, move- terminal phalanx of the fingers and toes, concentrated
ment) and any associated symptoms such as dyspnoea. around the nail base. It is seen by inspecting the nails
Ask also about the time course, i.e. onset, duration, con- (fingers and toes) from the side. Gross clubbing is usu-
stant or episodic. ally obvious (drumstick appearance of fingers), but mild
Chest pain made worse by inspiration and cough- clubbing may be difficult to detect (loss of the angle at
ing is called pleuritic pain. It is sharp and usually lo- the base of the nail and sponginess of the nail bed). The
calised to one area. It is caused by inflamed pleural pathological mechanism of clubbing is unknown, and
surfaces rubbing on one another. Causes include in- causes are shown in Table 3.3.
fection (may be associated with pneumonia), pneu-
mothorax, pulmonary embolism and mesothelioma or Breath sounds
metastatic tumours to the pleura. Pleurisy may also be
caused by connective tissue diseases such as rheumatoid Normal breath sounds are caused by the turbulent flow
arthritis. of air through the airways (not the alveoli). They are
Chest wall pain may be easily confused with pleuritic transmitted to the chest wall through the lungs (see
pain, as it is often sharp, but it can be reproduced by Table 3.4).
movement of the thoracic spine, chest or shoulders, and
by eliciting tenderness with mechanical pressure. Com-
mon causes include intercostal nerve entrapment, per- Table 3.3 Causes of clubbing
sistent cough, muscular strains, rib fracture and Tietze’s
Respiratory Bronchial carcinoma, more commonly
syndrome (costochondritis).
large cell than small cell
Adull, constant severe chest wall pain may be due Chronic suppurative lung disease
to invasion of the thoracic wall by malignancy. Other Bronchiectasis
causes include thoracic herpes zoster – a persistent pain, Lung abscess
which may be burning and last several days before the Chronic empyema
Pulmonary fibrosis
rash appears.
Idiopathic pulmonary fibrosis
Retrosternal pain may be due to tracheitis or medi- Cystic fibrosis
astinal disease (lymphoma, mediastinitis) but is more Asbestosis
commonly cardiac. Cardiovascular Cyanotic congenital heart disease
Infective endocarditis
Gastrointestinal Cirrhosis, especially primary biliary
Non-respiratory chest pain cirrhosis
Central chest pain, particularly if radiating to the neck Inflammatory bowel disease
or arms, is more likely to be cardiac. Pericarditis causes Coeliac disease
Idiopathic Familial usually before puberty
a sharp retrosternal/precordial pain which may mimic Idiopathic
pleuritic pain as it may be exacerbated by deep inspira- Rare Thyroid acropachy
tion, but is classically relieved by leaning forwards. Pain Pregnancy
at the shoulder tip is often referred pain from the di- Unilateral clubbing
Bronchial arteriovenous aneurysm
aphragm, and may reflect an abdominal cause such as
Axillary artery aneurysm
cholecystitis. Equally, respiratory disease may manifest