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Taking a comprehensive chest pain history is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough chest pain history. Check out the chest pain history OSCE mark scheme here. 

Opening the consultation

Introduce yourself – name / role

Confirm patient details – name / DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable

Presenting complaint

It’s important to use open questioning to elicit the patient’s presenting complaint

“So what’s brought you in today?”   or  “Tell me about your symptoms”

 

Allow the patient time to answer, trying not to interrupt or direct the conversation.

 

Facilitate the patient to expand on their presenting complaint if required.

“Ok, so tell me more about that”  “Can you explain what that chest pain was like?”

History of presenting complaint

Gain further details about the chest pain using SOCRATES

Site – where is the pain (e.g. central chest)

 

Onset:

  • Duration of pain (important when considering angina vs acute coronary syndrome)
  • Did it come on suddenly or has it been gradually building?
  • What was the patient doing at the time of onset? (exertional / at rest)

 

Character:

  • Aching / crushing – typical of acute coronary syndrome (ACS)
  • Sharp pain that’s worse on inspiration (pleuritic) –  pulmonary embolus / pneumothorax

 

Radiation:

  • Does the pain move anywhere else?
  • Left arm and jaw is typical of ACS
  • Radiation through to the back is associated with aortic dissection

 

Associated symptoms:

  • Dyspnoea – exertional? / orthopnea? / paroxysmal nocturnal dyspnoea?
  • Sweating / clamminess / nausea – associated with ACS
  • Cough – duration? / productive of sputum? (pneumonia) / haemoptysis? (PE)
  • Palpitations – ask patient to tap out the rhythm
  • Syncope / dizziness – postural? / exertional? / random?
  • Oedema – peripheral oedema (e.g. lower limbs) 
  • Fever – pericarditis / costochondritis / pneumonia 

 

Time course:

  • Duration – minutes / hours / days / weeks?
  • Worsening / improving / fluctuating?

 

Exacerbating / relieving factors:

  • Anything make the pain worse?
    • Inspiration (PE / pneumothorax / pneumonia)
    • Exertion (ACS / PE / pneumothorax / pneumonia)
    • Lying flat (pericarditis)

 

  • Anything make the pain better?
    • GTN spray (ACS or oesophogeal spasm)
    • Leaning forward (pericarditis)

 

Severity – on a scale of 0-10 how severe is the pain?

 

Has the patient had chest pain like this before? 

  • If the patient has angina, is this pain similar or different?

 

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms

Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

 

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.

Continue to periodically summarise as you move through the rest of the history.

 

Signposting

Signposting involves explaining to the patient:

  • What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
  • What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history

Cardiovascular disease:

  • Angina
  • Myocardial infarction – bypass grafts / stents
  • Hypertension
  • Hyperlipidaemia
  • Aortic aneurysm / dissection

 

Respiratory disease:

  • Pneumonia
  • Pneumothorax
  • Pulmonary embolus

 

Gastrointestinal disease:

  • Gastro-oesophageal reflux
  • Oesophageal spasm

 

Other medical conditions

Surgical history – bypass graft / stents / valve replacements

Acute hospital admissions?when and why?

Drug history

Regular prescribed medication?

  • Antiplatelets or anticoagulants?
  • GTN spray?

Contraceptive pill – increased risk of thromboembolic disease (e.g. PE)

Over the counter drugs

Herbal remedies

ALLERGIES – ensure to document these clearly

Family history

Cardiovascular disease at a young age – myocardial infarction / hypertension / thrombophilia

Are parents still in good health?if deceased sensitively determine age and cause of death

Social history

Smoking How many cigarettes a day? How many years have they smoked for?

Alcohol – How many units a week? – type / volume / strength of alcohol

Recreational drug usee.g. Cocaine – coronary artery vasospasm 

Diet  Overweight? Fatty foods? Salt intake? – cardiovascular risk factors

Exercise – baseline level of patient’s day to day activity

 

Living situation:

  • House/bungalow? – adaptations / stairs 
  • Who lives with the patient? – is the patient supported at home?
  • Any carer input? – what level of care do they receive?


Activities of daily living:

  • Is the patient independent and able to fully care for themselves?
  • Can they manage self hygiene / housework / food shopping?

 

Occupation – sedentary jobs increase cardiovascular risk – e.g. lorry driver

Systemic enquiry

Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).

Choosing which symptoms to ask about depends on the presenting complaint and  your level of experience.

 

Cardiovascular – Chest pain / Palpitations  / Dyspnoea /  Syncope / Orthopnoea  / Peripheral oedema 

RespiratoryDyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit 

Urinary –  Volume of urine passed / Frequency / Dysuria  / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Musculoskeletal – Bone and joint pain / Muscular pain 

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

Closing the consultation

Thank patient

Summarise history

Differential diagnoses of chest pain

Below is a selection of differential diagnoses that can present with chest pain, with included typical presenting patterns.

 

Cardiovascular

Acute coronary syndrome:

  • Central crushing chest pain.
  • Radiating to left arm / jaw.
  • Duration of more than 20 minutes.
  • Associated with sweating / clamminess / nausea / shortness of breath.
  • Symptoms are often worsened by exertion and improved with GTN spray.

 

Stable angina:

  • Central chest pain
  • Radiating to left arm / jaw
  • Duration less than 20 minutes with full resolution
  • Often triggered by exertion and resolved with GTN spray / rest
  • Associated with shortness of breath

 

Pericarditis:

  • Central chest pain
  • Worsened by lying flat and improved by leaning forwards
  • Patient may have had multiple episodes in the past

 

Aortic dissection:

  • Central chest / abdominal pain
  • Radiating through to the back
  • “Tearing” in nature
  • May have associated syncope / dizziness due to haemodynamic instability

 

Respiratory

Pneumonia:

  • Sharp chest pain worsened by inspiration (pleuritic)
  • Associated cough, shortness of breath, fever and malaise

 

Spontaneous pneumothorax:

  • Sudden onset sharp chest pain
  • Pleuritic in nature
  • Shortness of breath

 

Pulmonary embolism:

  • Sudden onset chest pain
  • Shortness of breath
  • Haemoptysis (rare)

 

Gastrointestinal

Gastro-oesophageal reflux:

  • Epigastric / chest pain
  • Burning in nature
  • Worsened by lying flat

 

Oesophageal spasm:

  • Epigastric / central chest pain
  • Relieved by GTN spray (hence can be confused with ACS)
  • No associated shortness of breath

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