A 57-year-old male presents to his local A&E department complaining of chest pain.
“Doctor, my chest, it’s still hurting. What’s going on?”
Use SOCRATES to gather further information about the chest pain:
Site – where exactly is the pain?
Onset – sudden or gradual?
Character – sharp / dull / crushing?
Radiation – does it move anywhere?
Associated symptoms – shortness of breath / pre-syncope / syncope
Timing – duration of chest pain?
Exacerbating & Relieving factors – what makes it worse or better?
Severity – on a scale of 1-10 – useful when later assessing impact of treatment
“The pain is in the middle of my chest and came on suddenly an hour ago whilst I was watching TV. It feels like I’ve got an elephant sat on my chest doctor, it’s awful. I had a bit of tingling in my neck and jaw, but that’s gone now. I feel really nauseated, I vomited once at home before the ambulance arrived. I do feel a little short of breath, which is weird, I’ve never had that before, maybe I’m just anxious. The pain isn’t affected by my position or by taking in a deep breath, it’s just always there. The pain has improved but it’s still aching and feels heavy, I’d say it was 8/10 at the start and it’s now about 5/10.”
Past medical history
Has the patient had chest pain in the past?
When was the first episode?
How frequently do the episodes occur?
Is there an obvious trigger – e.g. exertion
Have they been investigated for the chest pain?
Do they have a diagnosis of any cardiac problems?
Any other medical problems? (specifically cardiac risk factors)
Ischaemic heart disease
Family history of cardiac issues?
“I’ve never had chest pain like this before, maybe a few niggles every few months, over the last few years, but nothing like this! I didn’t bother going to the doctor about the niggles, as they always settled on their own and I’ve never been diagnosed as having any heart trouble.”
“I’ve got high blood pressure and cholesterol, I’m on tablets for those though.”
“I do smoke, about 20 a day and have done for the last 30 years”
“I’m not a drinker doctor, I like to stay healthy so I stay away from it”
“I don’t really do much exercise, but I get from the shops and back without any trouble”
The patient has a regular pulse, is tachycardic at 105 bpm and is hypertensive with a BP of 160/110
He has some xanthelasma around his eyes and also has corneal arcus.
Heart sounds are normal and his chest is clear.
There is no evidence of peripheral oedema.
The abdomen is soft and non-tender. There is no organomegaly. There is no expansile mass on palpation of the aorta.
Acute coronary syndrome
Dissecting aortic aneurysm
12 Lead ECG – looking for ischaemic changes
FBC – severe anaemia can cause an MI / raised WCC in pericarditis
U&E – abnormal electrolytes could cause arrhythmias