Chest Pain – History

Free medical revision on chest pain history taking skills for medical student exams, finals, OSCEs and MRCP PACES

Introduction (WIIPP)

Wash your hands
Introduce yourself: give your name and your job (e.g. Dr. Louise Gooch, ward doctor)
Identity: confirm you’re speaking to the correct patient (name and date of birth)
Permission: confirm the reason for seeing the patient (“I’m going to ask you some questions about what’s brought you in here today, is that OK?”)
Positioning: patient sitting in chair approximately a metre away from you. Ensure you are sitting at the same level as them and ideally not behind a desk.

Chest pain is an excellent example of when to use the mnemonic “SOCRATES”:
Site (central or left sided chest pain, retrosternal pain, epigastric pain)
Onset (sudden onset, how quickly it progressed, relation to exertion [if related to exertion, is it always related to exertion or occasionally at rest])
Character (crushing, heavy, tight, pleuritic [worst with breathing], burning)
- Some patients may struggle to explain the character of their pain. If this the case, give them a list of options (e.g. tight, sharp, dull or burning)

Radiation (radiating to left arm, neck, jaw [ACS]; back [pancreatitis, aortic dissection])
Alleviating factors (rest, glycerol trinitrate [GTN – suggestive of ACS]; sitting forward [pericarditis])
Timing (relation to exertion or food; any positional element)
Exacerbating factors
- Arm movement, pressing on chest (suggests musculoskeletal)
- Exercise, effort (suggest cardiac)
Severity scale (1-10)
Associated symptoms
- Acute coronary syndrome (shortness of breath, sweating, nausea)
- Other cardiac symptoms (palpitations, peripheral oedema, paroxysmal nocturnal dyspnoea, orthopnoea)
- Abdominal (heartburn, burping, previous history of gastroesophageal reflux)
- Psychosomatic (anxiety, history of panic attacks)
- Constitutional symptoms (fever, coryza)

Vascular disease in any organ
- Cardiac
  - Angina; previous mycardial infarction; previous angioplasty or coronary artery bypass graft surgery (CABG); stents (how many, bare metal or drug-eluting)
- Peripheral
  - Claudication, previous peripheral vascular disease
- Neurological
  - Previous stroke, transient ischemic attack
Risk factors for cardiovascular disease
- Hypertension
- Hypercholesterolemia
- Diabetes
- Smoking
- Family history (heart attack under 60 years old, familial hypercholesterolemia)
Risk factors for DVT/PE
- Recent surgery (under three months), malignancy, immobility
- Inherited coagulopathy (e.g. protein C or S deficiency)
- Relevant medications (e.g. oral contraceptive pill / hormone replacement therapy)
Risk factors for pneumothorax
- Tall, thin men in particular
- Known connection tissue disease (e.g. Marfans)
- Smoking history

Full drug history including recreational and over-the-counter (OTC) medications. In particular:
Cardiac medications
- Beta-blockers, diuretics, antiplatelet agents, GTN spray
Gastric irritants
- Non steroidal anti inflammatories (NSAIDs), steroids, bisphosphonates
Procoagulant medications
- Oral contraceptive pill, hormone replacement therapy (HRT)
Recreational drug use
- Cocaine (common cause of coronary artery spasm in young people)