Chest Pain History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you about the pain you have been experiencing in your chest. I will ask you some questions to try to determine what might be causing it. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presentation, for example “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interruption. This is referred to as the ‘golden minute’ and can provide valuable information about why the patient has sought medical attention as well as cues surrounding their ideas, concerns, and expectations (ICE) to explore later in the consultation.

History of Presenting Complaint

Next you need to gather more specific information about the patient’s presenting complaint to establish the differential diagnosis. You can use a mixture of open and closed questions. 

An example of an open question here would be: “How would you describe the pain?” or “Have you noticed any other symptoms alongside the chest pain?”. Examples of closed questions include: “Is the pain sharp or dull?” or “Does the pain come on with exertion?”

When taking a pain history, it is useful to use the SOCRATES mnemonic to structure your questioning:

• Site – where in the chest is the pain? E.g., central, left-sided, etc.
• Onset – when did the pain start, and what happened? How long has it been going on?
• Character – what type of pain is the patient experiencing? E.g., sharp, dull ache, pressure-like, etc.
• Radiation – does the pain travel anywhere else from the main site? E.g., to the neck or jaw.
• Associated symptoms – does the patient experience any other symptoms alongside the pain? E.g., sweating, nausea breathlessness.
• Timing – what is the time course of the pain? How long does it last? Is it constant or intermittent?
• Exacerbating and relieving factors – what makes the pain better? Does anything make the pain worse?
• Severity – on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable, how would the patient rate the severity of their pain?

System-specific History

After establishing further information about the chest pain, you need to gather any relevant system-specific information. In the case of chest pain, the system in question is the cardiovascular system. Try to think of symptoms that may present alongside chest pain, and ask about these, as well as questions that will provide important information about the patient’s overall cardiovascular health and risk factors.

It is important not only to ask these questions, but also to consider why the patient’s answers are important in narrowing down the differential diagnosis. 

For example, the presence of nausea and sweating alongside chest pain may lead you to consider acute coronary syndrome (ACS) in the differential. However, the absence of either of these symptoms, combined with the presence of breathlessness and unilateral leg swelling, would make a diagnosis of pulmonary embolism (PE) much more likely.

Cardiovascular system-specific questions to ask include but are not limited to:

• Nausea & vomiting – nausea associated with chest pain is a common symptom of acute coronary syndrome and may indicate a serious cause of chest pain which requires urgent management.
• Sweating – sweating associated with chest pain is another common symptom of ACS. Pericarditis or myocarditis may also present with low-grade fever, while pyrexia with cough and chest pain may indicate pneumonia.
• Shortness of breath – breathlessness with chest pain suggest differentials including PE, pneumothorax, pneumonia, or aortic dissection.
• Palpitations – chest pain with palpitations can be a presentation of anxiety or a panic attack. A patient presenting with an arrhythmia who then develops chest pain requires urgent review, as chest pain is one of the life-threatening features of several arrhythmias e.g., supraventricular tachycardia (SVT).
• Lightheadedness – chest pain with lightheadedness or pre-syncope is a concerning symptom and may be associated with arrhythmia or myocarditis.
• Activity levels – understanding the patient’s baseline activity level is important for assessing cardiovascular risk. Inactivity or a sedentary lifestyle are risk factors for cardiovascular events, e.g., myocardial infarction or stroke. 
• Exercise tolerance – is the patient’s activity or exercise limited by their symptoms, e.g., breathlessness or chest pain in angina? Has their exercise tolerance changed? Worsening exercise tolerance can be a useful measure of disease progression.
• Diet – does the patient’s diet contribute to their cardiovascular risk, e.g., a high fat, high salt diet, convenience food, takeaways, etc.

Relevant Systems Review

A systems review is a useful tool to ensure no important information from the history has been missed. However, it is key to consider which systems are relevant to review so that your questions remain relevant to the presenting complaint.

Relevant systems to review when taking a history of chest pain include:

• Respiratory – does the patient have any upper respiratory symptoms, e.g., nasal congestion, sore throat? Respiratory tract infections can cause pericarditis or myocarditis. A history of a productive cough and chest pain may lead you to consider pneumonia, whereas significant breathlessness with chest pain may indicate PE or pneumothorax.
• Gastrointestinal – gastro-oesophageal reflux disease (GORD) is a common differential for chest pain, as heartburn is felt as retrosternal pain and can be difficult to differentiate from myocardial ischaemia. Pain after eating, or triggered by fatty, acidic or spicy foods as well as large, late meals may suggest GORD as a differential.
• Musculoskeletal – has there been any recent trauma or injury to the chest? Chest trauma can cause rib fractures, and repetitive or strenuous movement can lead to costochondritis. Musculoskeletal chest wall pain causes tenderness when the chest wall is pressed worsens with movement.
• Psychiatric – chest pain can be a symptom of anxiety or panic disorder, especially if there is an emotional trigger.

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you; some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing this pain?”
• Concerns – “Is there anything that is worrying you about this chest pain?” ‘Have you read or Googled anything about your symptoms that has worried you?”
• Expectations – “Was there anything specifically you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note when an existing condition may be of significance in the context of the presenting complaint of chest pain, e.g., the patient has previously been told they have ischaemic heart disease (IHD) or hypertension (both conditions increase cardiovascular risk), or they have an underlying condition that increases their risk of a PE e.g., thrombophilia, pregnancy, malignancy. Don’t forget to ask about prior similar episodes of this presenting complaint.

Ask about previous surgery the patient may have undergone, especially if it will help to rule in or out differential diagnoses, e.g., the patient has presented with chest pain and breathlessness and they had major surgery a week ago (increased venous thromboembolism risk), or a patient presenting with exertional chest pain who had a coronary artery bypass graft (CABG) years ago (known IHD increases cardiovascular risk).

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications that the patient may not think to volunteer, e.g., over the counter medications, herbal or alternative medication, contraception, HRT, injections such as vitamin B12. Check whether the patient is compliant with their medication and taking it as prescribed.

Try to think about whether the information you are given could be relevant to the differential diagnosis, e.g., the patient has presented with exertional chest pain and reports they have not been compliant with their angina medication (poor disease control). Remember that certain medications may cause epigastric pain as a side effect which may present as “chest pain”, e.g., NSAIDs with no gastric protection.

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, beyond their presenting complaint.

• Who do they live with? Do they have a social support network e.g., if receiving a debilitating diagnosis.
• Do they work? Are they able to work with their current symptoms, and does work need to be adapted, e.g., a physically demanding job and exertional symptoms? Is their job active or sedentary? Could they increase physical activity on their commute to work, e.g., walk or cycle to work?
• Do they drive? Does their condition affect their ability to drive or attend appointments? Do their symptoms occur while driving, e.g., angina. Do they need to inform the DVLA?
• Have they had contact with someone with similar symptoms?
• Have they recently returned from travelling abroad?
• Do they smoke? Smoking increases cardiovascular risk, and patients should be encouraged to cut down or stop whenever possible.
• Do they drink alcohol? Alcohol increases cardiovascular risk.
• Do they use recreational drugs? Some recreational drugs increase the risk of cardiac events, e.g., cocaine-induced myocardial ischaemia, heart failure, cardiomyopathy, etc.

Try to think about the relevance of the information you are given, e.g., a young patient with no cardiovascular risk factors presents with ischaemic-sounding chest pain. When you take a full history they are a regular cocaine user and so their risk of myocardial infarction is now much greater than it was without this information. 

Family History

Does anyone in the family have cardiovascular disease, e.g., IHD, angina, hypertension, hypercholesterolaemia, or diabetes? A family history of cardiovascular disease is a risk factor for an individual developing cardiovascular disease, especially if diagnosed at an early age, e.g., angina or a heart attack in a first-degree relative aged <60 years-old. 

Do any other health conditions run in the family, e.g., inherited thrombophilia, which may increase risk of developing PE?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further by way of examination, bedside tests or further investigation/imaging.

Last updated Jan 2025

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