Chest pain history
Before starting
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the nature of his chest pain,
and obtain his consent.
• Ensure that he is comfortable.
The history
• Name, age, occupation, and ethnic origin.
Presenting complaint and history of presenting complaint
• Ask about the nature of the chest pain. Use open questions and give the patient the time to
tell his story. Also remember to be empathetic: chest pain can be a very frightening experience.
• Elicit the patient’s ideas, concerns and expectations (ICE).
• As with any pain history, the mnemonic SOCRATES can help develop your differential diagnosis:
–– Site: where exactly is the pain?
–– Onset and progression: when did the pain start and how has it changed or evolved?
–– Character: what type of pain is it (e.g. dull, sharp, or crushing)?
–– Radiation: does the pain move anywhere (e.g. into the jaw, arm, or back)?
–– Associated symptoms and signs: ask specifically about sweating, nausea and vomiting, shortness
of breath, cough, haemoptysis, dizziness, and palpitations
–– Timing and duration: does the pain occur at particular times of the day? How long does each
episode last?
–– Exacerbating and alleviating factors: does anything make the pain better or worse (e.g. exercise,
movement, deep breathing, coughing, cold air, large or spicy meals, alcohol, rest, GTN,
sitting up in bed)?
–– Severity: “How would you rate the pain on a scale of 1 to 10, with 1 being no pain at all and 10
being the worst pain you have ever experienced?”
–– effect on everyday life: ask in particular about exercise tolerance and sleep
• Ask about any previous episodes of chest pain.
Past medical history
• Current, past, and childhood illnesses.
• In particular, ask about risk factors: coronary heart disease, myocardial infarction, stroke, pneumonia,
pulmonary embolism, deep vein thrombosis, hypertension, hyperlipidaemia, diabetes,
smoking, alcohol use, and recent long-haul travel.
• Recent trauma or injury.
• Surgery.
Drug history
• Prescribed medication, including the oral contraceptive pill if female.
• Over-the-counter medication.
• Illicit drugs.
• Allergies.
Clinical Skills for OSCEs
22 Station 10 Chest pain history
Family history
• Parents, siblings, and children. Ask specifically about heart disease, hypertension, and other
heritable cardiovascular risk factors.
Social history
• Employment.
• Housing.
• Hobbies.
After taking the history
• Ask the patient if there is anything else that he might add that you have forgotten to ask. This is
an excellent question to ask in clinical practice, and an even better one to ask in exams.
• Thank the patient.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to examine the patient and possibly order some investigations, in
particular:
• ECG to look for or help rule out ischaemic heart disease.
• Blood tests including
–– troponins to look for or help rule out myocardial infarction
–– D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the
diagnosis but a positive result does not confirm it)
–– inflammatory markers such as white cell count and CRP for suggestion of pneumonia
• Chest X-ray for signs of pneumonia or pneumothorax.
• CTPA or V/Q scan if the history is suggestive of a pulmonary embolism.
Conditions most likely to come up in a chest pain history station
Angina:
• Heavy retrosternal pain which may radiate into the neck or left arm
• Brought on by effort or emotion and relieved by rest and nitrates
• Risk factors for ischaemic heart disease are likely
• A family history of ischaemic heart disease is likely
Myocardial infarction (MI):
• Pain typically comes on over a few minutes
• Pain is similar to that of angina but is typically severe, long-lasting (> 20 minutes), and
unresponsive to nitrates
• Often associated with sweating, nausea, and breathlessness
• Risk factors for ischaemic heart disease are likely
• A family history of ischaemic heart disease is likely
Cardiovascular and respiratory medicine
Station 10 Chest pain history 23
Pleuritic pain:
• Sharp, stabbing, ‘catching’ pain
• May radiate to the back or shoulder
• Typically aggravated by deep breathing and coughing
• Can be caused by pleurisy which can occur with pneumonia, pulmonary embolus, and
pneumothorax, or by pericarditis which can occur post-MI, in viral infections, and in autoimmune
diseases
• Pleural pain is localised to one side of the chest and is not position dependent
• Pericardial pain is central and positional, aggravated by lying down and alleviated by sitting up or
leaning forward
• Dressler’s syndrome (post-MI syndrome) is characterised by pleuritic chest pain from pericarditis
accompanied by a low-grade fever, and can occur up to three months following an MI
Pulmonary embolus:
• Sharp, stabbing pain that is of sudden onset
• May be associated with shortness of breath, haemoptysis, and/or pleurisy
• Typically aggravated by deep breathing and coughing
• May be a history of recent surgery, prolonged bed rest, or long-haul travel
Gastro-oesophageal reflux disease:
• Retrosternal burning
• Clear relationship with food and alcohol, but no relationship with effort
• May be associated with odynophagia and nocturnal asthma
• Aggravated by lying down and alleviated by sitting up and by antacids such as Gaviscon or milk
Musculoskeletal complaint e.g. costochondritis:
• May be associated with a history of physical injury or unusual exertion
• Pain is aggravated by movement, but is not reliably alleviated by rest
• The site of the pain is tender to touch
Panic attack:
• Rapid onset of severe anxiety lasting for about 20–30 minutes
• Associated with chest tightness and hyperventilation
Aortic dissection:
• Sudden onset, sharp, tearing pain that is maximal at the time of onset
• Radiates to the back
If you cannot differentiate angina from gastro-oesophageal reflux disease and there are
no signs of ischaemia on the ECG, advise an exercise ECG stress test. If this is negative,
consider a therapeutic trial of an antacid or a nitrate.