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History taking for Pleuritic chest pain

1. Patient Introduction and Demographics

  • Greet and introduce yourself

  • Explain the purpose of the interview and obtain consent.

2. Presenting Complaints

  • Record the main symptom in the patient’s own words (e.g., “sharp chest pain on breathing in”) and its duration.

3. History of Presenting Illness

  • Site: Ask where the pain is located (e.g., left/right chest, localized).

  • Onset: Sudden or gradual? Time of onset? Any precipitating event (e.g., trauma, exertion).

  • Character: Nature of pain (sharp, stabbing, pleuritic, dull).

  • Radiation: Does the pain move anywhere (shoulder, back, neck)?

  • Aggravating Factors: Worse with deep breathing, coughing, movement?

  • Relieving Factors: Any position or medication that relieves pain?

  • Timing: Duration, frequency, constant/intermittent, relation to breathing or posture.

  • Severity

  • Associated Symptoms:

    • Breathlessness, cough, sputum, hemoptysis, fever, night sweats, weight loss, malaise, joint pains.

    • Palpitations, syncope, leg swelling.

4. Review of Other Symptoms (Systemic Enquiry)

  • Respiratory: Cough (onset, duration, character, sputum—quantity, quality, color, hemoptysis),hemoptysis ,wheeze.

  • Cardiovascular: Palpitations, Syncope, orthopnea, paroxysmal nocturnal dyspnea, pedal edema.

  • Constitutional: Fever, night sweats, weight loss, malaise.

  • Musculoskeletal: Joint pains, trauma.

  • Gastrointestinal: Heartburn, vomiting.

5. Past Medical History

  • Previous similar episodes.

  • History of respiratory, cardiac, rheumatologic disease.

  • Recent infections, trauma, surgery, immobilization.

  • Tuberculosis, sickle cell disease, connective tissue disorders (important in India).

  • Recent travel, migration, or contact with TB patients (relevant in India).

  • Risk factors for DVT/PE: immobilization, surgery, malignancy, oral contraceptive use.

7. Family History

  • Similar illnesses in family (e.g., TB, autoimmune diseases).

  • History of cardiac, thromboembolic, respiratory diseases.

8. Personal History

  • Diet, sleep, bowel and bladder habits.

  • Smoking (pack years), alcohol use, occupation (exposure to dust, chemicals, TB).

Drug History

  • Current and recent medications (name, dose, frequency, route).

  • Over-the-counter and traditional medicines.

  • Side effects or allergies.

  • Use of anticoagulants, oral contraceptives, steroids, or immunosuppressants.

9. Socioeconomic History

  • Socioeconomic status, living conditions (overcrowding, sanitation—relevant for TB risk)

Case Presentation: Pleuritic Chest Pain

Patient Details
Name: Mr. Vishal Sahu
Age/Sex: 35 years/Male
Occupation: Farmer
Date of Admission:
Date of Examination

Informant : Patient himself

Presenting Complaints

  • Chest pain (right-sided, pleuritic in nature) for 2 weeks

  • High-grade fever for 2 weeks

  • Cough for 2 weeks

  • Difficulty breathing for 2 weeks

  • Generalized weakness for 2 weeks3

History of Presenting Illness
Mr. Vishal Sahu, a previously healthy 35-year-old male, presented with a 2-week history of right-sided chest pain. The pain was sharp, stabbing, and worsened on deep inspiration and coughing (pleuritic). It did not radiate to the back, neck, or arm. The pain was continuous, severe, and interfered with daily activities.

He reported associated high-grade, intermittent fever with chills and rigors. He also had a persistent cough, initially dry but later productive with scanty, yellowish sputum. He denied hemoptysis.

He experienced progressive shortness of breath, initially on exertion and now at rest. There was no history of orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope.

There was no history of recent travel, trauma, or immobilization. No history of chest injury. He denied any history of similar complaints in the past.

No history of weight loss, night sweats, or loss of appetite. No joint pains, skin rashes, or oral ulcers.

Past Medical History

  • No known hypertension, diabetes, tuberculosis, asthma, or other chronic illnesses.

  • No previous hospitalizations or surgeries.

  • No known exposure to tuberculosis.

  • No recent travel or contact with sick individuals.

Family History

  • No family history of tuberculosis, asthma, hypertension, diabetes, malignancy, or other chronic diseases.

  • No similar complaints among family members.

Personal History

  • Diet: Mixed

  • Sleep: Disturbed due to symptoms

  • Bowel and bladder habits: Normal

  • Non-smoker, non-alcoholic.

  • No addictions

Drug History

  • Currently on tablet ceftriaxone, theophylline, IV fluids (normal saline), and metronidazole as per hospital prescription.

  • No history of drug allergies.

Socioeconomic History

  • Farmer by occupation

  • Socioeconomic status: Lower middle class

  • Lives in a rural area in a joint family setup.

  • 10 members in a 3 roomed house, overcrowding present

  • Drinks water from a sanitary well

Review of Systems

  • Cardiovascular: No chest tightness, palpitations, or leg swelling

  • Gastrointestinal: No nausea, vomiting, abdominal pain, or jaundice

  • Musculoskeletal: No joint pains or swelling

  • Neurological: No headache, seizures, or weakness

Summary
Mr. Vishal Sahu, a 35-year-old male farmer, presented with a 2-week history of right-sided pleuritic chest pain, high-grade fever, productive cough, and breathlessness. Examination and investigations revealed pleural effusion. There is no significant past, family, or drug history. He is currently receiving antibiotics and supportive care.

Provisional Diagnosis:
Right-sided pleural effusion, likely infective etiology (consolidation/parapneumonic effusion).

Commonly Asked Viva Questions on Pleuritic Chest Pain (with Answers)

1. What is pleuritic chest pain?
Pleuritic chest pain is a sharp, stabbing pain in the chest that worsens with deep inspiration, coughing, or movement. It is caused by irritation or inflammation of the parietal pleura, which is innervated by intercostal and phrenic nerves.

2. What are the common causes of pleuritic chest pain?
Common causes include:

  • Pneumonia

  • Pulmonary embolism

  • Pneumothorax

  • Pleurisy (primary pleural inflammation)

  • Pericarditis

  • Rib fracture

  • Connective tissue diseases (e.g., SLE, rheumatoid arthritis)

  • Malignancy involving pleura.

3. How do you differentiate pleuritic chest pain from angina?

  • Pleuritic pain is sharp, localized, and worsens with breathing or coughing, while angina is typically a dull, pressure-like pain, often central, radiating to the left arm or jaw, and is related to exertion, not respiration7.

  • Pleuritic pain is not relieved by nitrates, whereas angina often is.

4. What are the important points to elicit in the history of a patient with pleuritic chest pain?

  • Site, onset, character, radiation, duration, severity, aggravating and relieving factors

  • Associated symptoms: cough, fever, breathlessness, hemoptysis, recent travel or immobilization, trauma, past similar episodes.

5. What are the key clinical features of pneumonia presenting with pleuritic chest pain?

  • Gradual onset of sharp chest pain worsened by deep inspiration

  • Associated with productive cough, shortness of breath, fever, and malaise.

6. How does pulmonary embolism typically present?

  • Sudden onset pleuritic chest pain, often with shortness of breath and sometimes hemoptysis

  • Risk factors include recent surgery, immobilization, long-haul travel, malignancy, or oral contraceptive use.

7. What is the pathophysiology of pleuritic chest pain?
Pleuritic chest pain results from irritation or inflammation of the parietal pleura, which is richly innervated by branches of the intercostal and phrenic nerves. The visceral pleura lacks sensory innervation, so pain arises only when the parietal pleura is involved.

8. What investigations would you order for a patient with pleuritic chest pain?

  • Chest X-ray

  • Complete blood count, ESR/CRP

  • ECG (to rule out cardiac causes)

  • D-dimer (if PE suspected)

  • CT pulmonary angiography (if PE suspected)

  • Sputum analysis (if infection suspected)

  • Pleural fluid analysis if effusion present.

9. What are the complications of pleural effusion?

  • Empyema (infected effusion)

  • Fibrosis and pleural thickening

  • Respiratory compromise

10. How do you manage pleuritic chest pain?

  • Treat underlying cause (antibiotics for pneumonia, anticoagulation for PE, chest tube for pneumothorax)

  • Analgesics for pain relief

  • Supportive care (oxygen, fluids if needed)5.

11. What is the significance of a pericardial friction rub in a patient with pleuritic chest pain?
A pericardial friction rub suggests pericarditis, which can present with pleuritic chest pain that is worse on lying down and relieved by sitting forward.

12. How can you distinguish between pleuritic pain due to musculoskeletal causes and that due to pleural disease?
Musculoskeletal pain is often reproducible on palpation and may follow trauma or exertion, whereas pleural pain is not tender on palpation and is more closely related to the respiratory cycle.