Medically Fit For Exams
Medically Fit For Exams

Chest pain history taking

 

  • Wash hands and introduce yourself

Differential diagnoses

Angina

Anaemia

MI/ACS

Pericarditis

GORD

PE

Pneumonia

Lung cancer

Pulmonary oedema, heart failure

Costochondritis

Muscle strain

  • Check the patient’s name and DOB
  • Ask if you can talk to them before they see the doctor

 

History of presenting complaint

  • Ask what has brought them in today
  • Ask them to tell you a bit more about the chest pain
  • Use SOCRATES mnemonic to investigate the pain
    • Site
      • Retrosternal (angina, MI, GORD)
      • Chest (PE, pneumonia, cancer)
      • Ribs (costochondritis)
    • Onset
      • How long for?
      • Sudden onset? (PE, MI, individual angina attack
      • Injury? (musculoskeletal)
      • Exertion?
    • Character
      • Dull, squeezing, crushing (angina, MI)
      • Sharp/pleuritic (PE, pneumonia, pericarditis, ?cancer)
      • Burning (GORD)
      • Tearing/ripping sudden onset (aortic dissection)
    • Radiation
      • Left arm, jaw, neck, shoulder (angina, MI)
      • Throat, mouth (GORD)
    • Associated symptoms
      • SOB (angina, MI, PE, pneumonia, cancer)
      • Nausea (MI, pneumonia)
      • Pillows/gasping for breath in night (heart failure/pulmonary oedema)
      • Cough, sputum (PE, pneumonia, cancer)
      • Fever (pneumonia, PE)
      • Weight/appetite loss (cancer, pneumonia)
      • Sour taste in mouth (GORD)
    • Timing
      • Does it come and go?
      • Constant?
      • Have you had it before?
    • Exacerbating/relieving factors
      • Worse on movement or coughing (muscle, costochondritis)
      • Worse/only on exertion (angina
      • Worse on inspiration (PE
      • Worse after eating? (GORD)
      • Better with antacids? (GORD)
      • Better when sitting up? (pulmonary oedema, GORD, pericarditis (relieved by sitting forwards)21)
      • Better on rest (angina)
    • Severity
      • Pain scale
      • Impact on daily life
  • Note that anaemia can mimic/cause angina. Investigate whether the cause is anaemia if angina is your working diagnosis:
    • Leg claudication
    • Recent blood loss
    • Heavy periods
    • Blood in stools or urine
    • Melena
    • Reduce iron intake
    • Diarrhoea/malabsoption
  • Summarise and check what the patient has told you
  • ICE
    • Ask if there is anything in particular they were concerned about
    • Ask if there was anything they thought might be causing their symptoms

 

Past medical history

  • Ask if they have past or current health problems
  • Ask if they have had any surgery (PE)
  • Ask about
    • Hypertension
    • Hypercholesterolaemia
    • Angina
    • Diabetes
    • Reflux
    • Clotting/blood disorders (PE)
    • Cancer (PE)
    • Ask about long-haul flights (PE)
    • COPD (pneumonia)

 

Drug history

  • Ask if they take any medication, and if it has been changed
    • Inhalers, GTN
  • Ask about over the counter medications
  • Ask about supplements

 

Allergies

  • Ask if they have any allergies
  • Ask what happens

 

Family history

  • Ask if anyone in the family has had problems with chest pain
  • Ask if there is any family history of heart disease
    • Age of onset in immediate family
  • Family history of diabetes, high blood pressure, high cholesterol
  • Ask if any other health problems run in the family

 

 

Social history

  • Ask about smoking and pack years (MI, lung cancer, pneumonia)
  • Ask about drinking and weekly units
  • Ask about occupation
    • Especially heavy/manual work (musculoskeletal)
    • Effect of chest pain on work

 

Summary

  • Ask the patient if they have any questions or concerns
  • Ask if they think you’ve missed anything
  • Summarise again if appropriate
  • Thank the patient for talking to you

 

Angina

Central/retrosternal dull/squeezing/crushing chest pain on exertion, relieved by rest

Each episode with sudden onset and short duration (<20 minutes)

May radiate to arm or jaw, may have SOB

Unlikely to have: Nausea, vomiting, sweating

MI/ACS

Central/retrosternal dull/squeezing/crushing pain, sudden onset

Duration >20 mins, not relieved by rest or GTN spray

Radiation to jaw, neck, shoulder, arm

Associated SOB, nausea, vomiting, sweating, anxiety

Pericarditis

NB presents very similarly to GORD, but without influence of food

Pleuritic pain (worse on inspiration or cough), retrosternal

Relieved by sitting forward, worse when lying flat

PE

Sudden onset, pleuritic pain (sharp, worse on inspiration/coughing)

Associated with SOB, cough/haemoptysis, DVT (red, swollen calf)

History of malignancy, clotting disorder, long-haul travel, recent surgery, immobility, pregnancy

Pneumonia

More gradual, associated with cough + green sputum, SOB, fever, malaise, fatigue

Pleuritic (sharp, worse on inspiration/cough), may have haemoptysis

May have background of COPD, fibrosis, bronchiectasis

Pulmonary oedema/heart failure

SOB especially on exertion, lying down (orthopnoea: extra pillows, paroxysmal nocturnal dyspnoea)

Cough with pink frothy sputum, fatigue, leg oedema

Lung cancer

Cough with haemoptysis, weight loss, fatigue, smoking history

GORD

Retrosternal burning pain, worse after large meals, worse on lying down

Relieved by sitting up, antacids, water

Likely to have regurgitation sensation in throat and sour taste in mouth

Costochondritis

Pain in the ribs, associated with movement, relieved by rest, may have had initial trauma/injury

May be helped by painkillers/anti-inflammatories

Musculoskeletal

Localised pain associated with movement and relieved by rest

May have had initial trauma/injury, may do heavy/manual work

May be helped by painkillers/anti-inflammatories

 

 

 

 

 

Next steps

In all cases

Cardiovascular exam and respiratory exam, FBC, d-dimer (?)

Angina

ECG, echocardiogram, trial of GTN, troponin, BNP, CXR, angiogram

MI/ACS

Emergency protocol: 300mg aspirin, GTN, O2, pain relief/antiemetics, ECG, call 999, do ABCDE approach, PCI in a cath lab

Pericarditis

Blood cultures, ECG, echocardiogram, antibiotics, CRP

PE

Admit, D-dimer if low risk, calculate Well’s score, thrombolysis (?)

Pneumonia

Blood cultures, CRP, antibiotics, pulse oximetry, O2,

Heart failure

ECG, BNP, echocardiogram

Lung cancer

2 week wait CXR

GORD

Blood cultures, ECG, CXR + CRP to rule out pericarditis, endoscopy, PPIs

Musculoskeletal

Pain relief, d-dimer, sign off from work, physiotherapy

 

 

 

 

 

Chest pain history taking.docx
Microsoft Word document [19.2 KB]

Get social with us.

Print Print | Sitemap
© medicallyfitforexams.co.uk