Chest Pain

Question 1

What is always the first step when taking a history?

Answer 1

1. Wash hands
2. Introduce yourself to the patient including your name and role.
3. Confirm the patient’s name and date of birth.
4. Explain that you’d like to take a history from the patient.
5. Gain consent to proceed with history taking.

Question 2

How should the patient’s presenting complaint be explored?

Answer 2

Use open questioning to explore the patient’s presenting complaint:

“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
“Ok, can you tell me more about that?”

Question 3

How should the history of the presenting complaint be explored?

Answer 3

Use SOCRATES to gain further information:

Site
Onset
Character
Radiation
Associated symptoms 
Time course 
Exacerbating/relieving factors 
Severity

Question 4

Applying SOCRATES to chest pain:

Answer 4

Site

• “Where is the pain?”
• “Can you point to where you experience the pain?”

Onset
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?”

Character
Ask about the specific characteristics of the pain:
- “How would you describe the pain?”
- “Is the pain constant or does it come and go?”

Radiation
- “Does the pain spread elsewhere?”

Associated symptoms
- “Are there any other symptoms that seem associated with the pain?”

Time course
Clarify how the pain has changed over time:
- “How has the pain changed over time?”

Exacerbating or relieving factors

• “Does anything make the pain worse?”
• “Does anything make the pain better?”

Severity
- “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?”

Question 5

If a patient describes chest pain that was initially only present during exertion which is now also present at rest, what could this be?

Answer 5

Unstable angina

Question 6

Acute coronary syndrome:

• Chest pain?
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 6

Chest pain: Sudden onset central crushing chest pain radiating to the left arm and/or jaw lasting longer than 20 minutes.

Associated symptoms: sweating, clamminess, nausea and shortness of breath.

Exacerbating/relieving factors: Symptoms are often worsened by exertion and improved with GTN spray.

Question 7

What is GTN spray? Function?

Answer 7

Glyceryl trinitrate acts on vascular smooth muscles to produce arterial and venous vasodilation. The vasodilation results in a reduction of venous return and an improvement in myocardial perfusion with the result of a reduction in the work performed by the heart and hence reduced oxygen demand.

Question 8

Stable angina:

• Chest pain?
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 8

Chest pain: 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.

Associated symptoms: shortness of breath.

Exacerbating/relieving factors: Often triggered by exertion and resolved with GTN spray and/or rest.

Question 9

What is pericarditis? How does it differ from myocarditis or endocarditis?

Answer 9

Endo: inflammation of the inner lining of the heart’s chambers and valves.

Myo: inflammation of the heart muscle

Peri: inflammation of the tissue that forms a sac around the heart

Question 10

Pericarditis:

• Chest pain?
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 10

Chest pain: Gradual onset of central chest pain

Associated symptoms: fever and fatigue.

Exacerbating/relieving factors: worsened by lying flat and improved by leaning forwards.

Question 11

What is thoracic aortic dissection?

Answer 11

An aortic dissection when the inner layer of the aorta tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect).

Question 12

Thoracic aortic dissection:

• Chest pain?
• Associated symptoms?

Answer 12

Chest pain: Sudden onset central chest pain radiating through to the back and often described as ‘tearing’ in nature.

Associated symptoms: pre-syncope and syncope secondary to haemodynamic instability.

Question 13

Pneumonia:

• Chest pain?
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 13

Chest pain: Gradual onset of sharp chest pain

Associated symptoms: productive cough, shortness of breath, fever and malaise.

Exacerbating/relieving factors: worsened by deep inspiration (pleuritic in nature).

Question 14

Pulmonary embolism:

• Chest pain?
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 14

Chest pain: Sudden onset chest pain

Associated symptoms: shortness of breath and haemoptysis (rare).

Exacerbating/relieving factors: worsened by deep inspiration (pleuritic in nature).

Question 15

Gastro-oesophageal reflux:

• Chest pain:
• Associated symptoms?
• Exacerbating/relieving factors?

Answer 15

Chest pain: Gradual onset central chest pain that is typically described as burning in character

Exacerbating/relieving factors: worsened by lying flat.

Associated symptoms: nausea and vomiting.

Question 16

When taking a cardiovascular history it’s essential that you identify risk factors for cardiovascular disease as you work through the patient’s history (e.g. past medical history, family history, social history).

What are important cardiovascular risk factors?

Answer 16

Hypertension
Hyperlipidaemia
Diabetes
Family history of cardiac disease
Smoking