Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Gather further details about the patient’s chest pain using the SOCRATES acronym.
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Ask about the location of the pain:
“Where is the pain?”
“Can you point to where you experience the pain?”
Clarify how and when the pain developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“Did the pain come on at rest or whilst you were exerting yourself?”
“How long did the pain last for?”
Ask about the specificcharacteristics of the pain:
“How would you describe the pain?”
“Is the pain constant or does it come and go?”
Ask if the pain movesanywhere else:
“Does the pain spread elsewhere?”
Ask if there are other symptoms which are associated with the pain:
“Are there any other symptoms that seem associated with the pain?”
Clarify how the pain has changed over time:
“How has the pain changed over time?”
This question can be useful to determine if the chest pain has become progressively worse over time. An example might be a patient describing chest pain that was initially only present during exertion which is now also present at rest (e.g. unstable angina).
Exacerbating or relieving factors
Ask if anything makes the pain worse or better:
“Does anything make the pain worse?”
“Does anything make the pain better?”
Assess the severity of the pain by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
This allows you to assess the patient’s response to treatments (e.g. pain was initially 8/10 and improved to 3/10 with GTN spray).
Typical presentations of chest pain
Acute coronary syndrome:
Sudden onset central crushing chest pain radiating to the left arm and/or jaw lasting longer than 20 minutes.
Associated symptoms can include sweating, clamminess, nausea and shortness of breath.
Symptoms are often worsened by exertion and improved with GTN spray.
Sudden onset central chest pain radiating to the left arm and/or jaw lasting fewer than 20 minutes with complete resolution of pain during rest.
Often triggered by exertion and resolved with GTN spray and/or rest.
Associated symptoms include shortness of breath.
Gradual onset of central chest pain worsened by lying flat and improved by leaning forwards.
Associated symptoms can include fever and fatigue.
Thoracic aortic dissection:
Sudden onset central chest pain radiating through to the back and often described as ‘tearing’ in nature.
Associated symptoms include pre-syncope and syncope secondary to haemodynamic instability.
Gradual onset of sharp chest pain worsened by deep inspiration (pleuritic in nature).
Associated symptoms include productive cough, shortness of breath, fever and malaise.
Sudden onset sharp chest pain worsened by deep inspiration.
Associated with shortness of breath.
Sudden onset chest pain worsened by deep inspiration (pleuritic in nature).
Associated symptoms include shortness of breath and haemoptysis (rare).
Gradual onset central chest pain that is typically described as burning in character and worsened by lying flat.
Associated symptoms can include nausea and vomiting.
Sudden onset central chest pain relieved by GTN spray (hence it is often confused with acute coronary syndrome).
Associated symptoms can include dysphagia, heartburn and regurgitation.
Cardiovascular risk factors
When taking a cardiovascular history it’s essential that you identify riskfactors for cardiovasculardisease as you work through the patient’s history (e.g. past medical history, family history, social history).
Important cardiovascular risk factors include:
Family history of cardiac disease
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Neurological: visual changes, motor or sensory disturbances, headache
Musculoskeletal: chest wall pain, trauma
Dermatological: rashes, ulcers
Past medical history
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
Ask if the patient has previously undergone any surgery (e.g. coronary artery bypass grafts, coronary artery stents, heart valve replacements):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
Examples of relevant medical conditions
Chronic kidney disease
Peripheral vascular disease
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medicationname, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any sideeffects from their medication:
“Have you noticed any side effects from the medication you currently take?”
Medications commonly prescribed to patients with medical conditions relevant to chest pain:
Ask the patient if they use recreationaldrugs and if so determine the type of drugs used and their frequency of use. Recreational drugs may be the underlying cause of a patient’s presentation with chest pain symptoms:
Cocaine, ecstasy and amphetamines activate the sympathetic nervous system and thus have similar cardiovascular effects which can include tachycardia (palpitations), blood pressure abnormalities (dizziness, headache) and coronary artery vasospasm (chest pain).
Opiates including morphine and heroin activate the parasympathetic nervous system leading to bradyarrhythmias and hypotension (syncope).
Cannabis activates the sympathetic nervous system at low doses (e.g. tachycardia, hypertension) and the parasympathetic nervous system at higher doses (e,g, bradycardia, hypotension).
Ask the patient if they gamble and if they feel this is a problem.
Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1
Ask if the patient what their diet looks like on an averageday. Take note of unhealthyfoods which are known to contribute to cardiovascular disease (e.g. high salt intake, high saturated fat intake).
Ask if the patient regularly exercises and if so clarify the frequency and activity type of exercise.
Ask about the patient’s current occupation:
Assess the patient’s level of activity in their occupation (sedentary jobs are associated with increased cardiovascular risk).
If the patient is experiencing chest pain and works with heavy machinery or at heights, it is important to advise them to take time off work until they have been fully investigated.
If the patient drives and has presented with chest pain it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues.
Closing the consultation
Summarise the keypoints back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.