11/13/24, 8\:08 PM Guide | Chest pain history

Chest pain history

Table of contents

Background

Chest pain is a very common presenting complaint that may be seen in any medical setting, depending on the acuity of onset.
It can often be related to serious disease, so it is very important to have a thorough approach to history taking.

Causes of chest pain

Pain can occur due to disease in any structure within the thorax and radiate from adjacent systems. When evaluating chest pain
and considering di
Cardiac causes
Acute coronary syndrome
ST-elevation myocardial infarction
Aortic dissection
Pericarditis
Angina
Acute heart failure
Non-cardiac causes
Respiratory\: pulmonary embolism, pneumothorax, pneumonia, lung cancer, asthma
Musculoskeletal\: rib fracture, bony metastasis, costochondritis
Gastrointestinal\: gastro-oesophageal recholecystitis, biliary colic,
pancreatitis
Dermatological\: shingles
Others\: anxiety
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 1/811/13/24, 8\:08 PM Guide | Chest pain history
Despite the array of di
This highlights the importance of a clear history taking and examination to exclude serious causes of chest
underlying cause. 1
pain.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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 o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
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 di
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 2/811/13/24, 8\:08 PM Guide | Chest pain history

History of presenting complaint

Gather further details about the patient's chest pain using the SOCRATES acronym.

SOCRATES

The SOCRATES acronym is a useful tool for exploring a patient’s symptoms in more detail, particularly with a presenting
complaint of pain.
Site
Ask about the location of the pain\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Onset
Clarify how and when the pain developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" D i d t h e p a i n c o m e o n a t r e s t o r w h i l s t y o u w e r e e x e r t i n g y o u r s e l f ?"
" H o w l o n g d i d t h e p a i n l a s t f o r ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?"
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Common descriptors of chest pain may include\:
‘crushing’
,
‘stabbing’
,
‘burning’ or ‘aching’
.
Radiation
Ask if the pain moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
" A r e y o u e x p e r i e n c i n g p a i n a n y w h e r e e l s e i n t h e b o d y ?"
Associated symptoms
Ask if there are other symptoms which are associated with the pain\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?"
Time course
Clarify how the pain has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
" H a v e y o u e x p e r i e n c e d t h i s p a i n b e f o r e ?"
" I s t h e p a i n s t i l l p r e s e n t n o w ?"
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\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?"
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?"
Severity
Assess the severity of the pain by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
" H o w d o e s t h i s c o m p a r e t o p r e v i o u s e p i s o d e s o f p a i n ?"
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).
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 3/811/13/24, 8\:08 PM Guide | Chest pain history
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
Stable angina
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
Pericarditis
Gradual onset of central chest pain worsened by lying
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
Pneumonia
Gradual onset of sharp chest pain worsened by deep inspiration (pleuritic in nature)
Associated symptoms include productive cough, shortness of breath, fever and malaise
Spontaneous pneumothorax
Sudden onset sharp chest pain worsened by deep inspiration
Associated with shortness of breath
Pulmonary embolism
Sudden onset chest pain worsened by deep inspiration (pleuritic in nature)
Associated symptoms include shortness of breath and haemoptysis (rare)
Musculoskeletal
Sudden or gradual onset, typically following exercise, strain or chest wall injury
Pain reproducible on palpation and can be worsened by deep inspiration (pleuritic in nature)
Gastro-oesophageal re
Gradual onset central chest pain that is typically described as burning in character and worsened by lying
Associated symptoms can include nausea and vomiting
Oesophageal spasm
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

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
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.
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 4/811/13/24, 8\:08 PM Guide | Chest pain history
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

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

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 di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry 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\:
Systemic\: fever, weight change, fatigue
Respiratory\: dyspnoea, cough, sputum, wheeze, haemoptysis
Gastrointestinal\: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
Genitourinary\: oliguria, polyuria
Neurological\: visual changes, motor or sensory disturbances, headache
Dermatological\: rashes, ulcers, oedema

Past medical history

Ask if the patient has any medical conditions\:
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 5/811/13/24, 8\:08 PM Guide | Chest pain history
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient has a medical condition, you should gather more details to assess how well-controlled the disease is and what
treatment(s) the patient receives. It is also important to ask about any complications associated with the condition,
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Examples of relevant medical conditions
When taking a cardiovascular history, you must identify pre-existing cardiovascular disease and risk factors for
cardiovascular disease.
Important pre-existing cardiovascular diseases include\:
Angina
Myocardial infarction
Stroke and TIA
Peripheral vascular disease
Atrial
Hypertension
Important cardiovascular risk factors include\:
Hyperlipidaemia
Obesity
Chronic kidney disease
Rheumatic fever
Diabetes mellitus
Smoking
Alcohol excess
For further information, read the Geeky Medics guide to hyperlipidaemia and hypertension.
Allergies
anaphylaxis).
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

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Examples of relevant medications examples
Medications relevant to a chest pain history include\:
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 6/811/13/24, 8\:08 PM Guide | Chest pain history
Anticoagulants (e.g. pulmonary embolism, atrial
Antiplatelets (e.g. coronary artery disease, cerebrovascular disease)
Statins (e.g. coronary artery disease)
Glyceryl trinitrate spray (e.g. angina, oesophageal spasm)
Calcium channel blockers (e.g. hypertension)
Diuretics (e.g. heart failure)
ACE inhibitors (e.g. hypertension)
Antibiotics (e.g. pneumonia)
Colchicine (e.g. pericarditis)
Proton pump inhibitors (e.g. gastro-oesophageal re
Oral hypoglycaemic agents (e.g. diabetes mellitus)

Family history

Ask the patient if there is any family history of diseases which may be associated with chest pain (e.g. coronary artery disease,
thromboembolic disease and familial hypercholesterolemia)\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y h e a r t p r o b l e m s ?"
" H a v e a n y o f y o u r p a r e n t s o r s i b l i n g s p r e v i o u s l y b e e n d i a gn o s e d w i t h a b l o o d c l o t ?"
' D o e s a n y o n e i n y o u r f a m i l y h a v e h i g h c h o l e s t e r o l ?"
Clarify at what age the disease developed as a disease developing at a younger age is more likely to be associated with
genetic factors\:
" A t w h a t a g e d i d y o u r f a t h e r s u
" W h e n w a s y o u r m o t h e r d i a g n o s e d w i t h a p u l m o n a r y e m b o l i s m ?"
If one of the patient's close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
" I' m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?"

Social history

Explore the patient's social history to both understand their social context and identify potential risk factors for medical
conditions which could present with chest pain.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stair lift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
For further information, read the Geeky Medics guide to smoking cessation.
Alcohol
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 7/811/13/24, 8\:08 PM Guide | Chest pain history
Record the frequency, type and volume of alcohol consumed on a weekly basis.
For further information, read the Geeky Medics guide to alcohol history taking.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Stimulant drugs such as cocaine, ecstasy and amphetamines are risk factors for myocardial infarction, heart failure and
arrhythmias.
2
Diet
Ask if the patient what their diet looks like on an average day. Take note of diets which are known to contribute to
cardiovascular disease such as excess intake of salt, saturated fat and ultra-processed food.
Exercise
Ask if the patient regularly exercises and if so clarify the frequency and activity type of exercise.
Occupation
Ask about the patient's current occupation and assess the impact of their symptoms on their ability to work.
Enquire speci
cardiovascular disease.
3-4
Driving
If the patient drives and has presented with chest pain, there may be certain circumstances in which they would need to stop
driving and inform the DVLA.
You can read more about speciDVLA guide for medical professionals.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. NICE CKS. C h e s t p a i n . 2023. Available from\: [LINK].
2. Dominic P, Ahmad J, Awwab H, et al. S t i m u l a n t D r u g s o f A b u s e a n d C a r d i a c A r r h y t h m i a s . Circulation\: Arrhythmia and
Electrophysiology. 2021. Available from\: [LINK].
3. Lunde L, Skare Ø, Mamen A, et al. C a r d i o v a s c u l a r H e a l t h E
P r o t o c o l f o r a T h r e e- Y e a r P r o s p e c t i v e F o l l o w-U p S t u d y o n I n d u s t r i a l W o r k e r s . 2020. International Journal of Environmental
Research and Public Health. Available from\: [LINK].
4. Kivimäki M, Kawachi I. W o r k S t r e s s a s a R i s k F a c t o r f o r C a r d i o v a s c u l a r D i s e a s e . Current Cardiology Reports. 2015. Available from\:
[LINK].

Reviewer

Dr Ryan Jennison
General Practitioner
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/history/chest-pain-history/ 8/8