Chest Pain Questions History Taking

Chest pain questions:

Where –> system involved

What –> pathology

How –> functional limitation

Why –> aetiology

1. Patient’s age
2. SOCRATES – site, onset, character, radiation, associated symptoms, time course, exacerbating/relieving factors, and severity.

Character:

• crushing or pressure –> cardiac
• tearing pain through to back –> dissection
• sharp, stabbing –> pulmonary
• burning, ‘indigestion’ –> GI

…but be careful with character, because there is lots of overlap

Onset:

• exertional –> IHD
• progressive onset at rest –> MI
• sudden onset –> PE, dissection or pneumothorax
• after meals –> GI

Location: superficial and localised –> somatic

Radiation:

• to the back –> dissection, pancreatitis, posterior ulcer (MI possible)
• arms/neck/jaw –> IHD
• located primarily in the back, especially interscapular –> dissection

Duration:

• maximal at onset –> aortic dissection
• lasts only for a few minutes –> IHD

Exacerbating/relieving factors:

• worsens with exertion, relieved with rest –> IHD
• related to meals –> GI
• worsens with respiration –> pulmonary, pericardial and musculoskeletal

Associated Sx:

• haemoptysis –> PE
• dyspnoea –> CV or pulmonary
• nausea and vomiting –> CV or GI

Previous episodes; ask about testing (ECG, echo or angiography)

1. Specific questions –

• HoPC:

· Associated with dyspnoea? Worse when lying down (orthopnoea)? How many pillows do you sleep with? Do you wake up at night, gasping for breath (paroxysmal nocturnal dyspnoea)?

· Ankle swelling (symmetrical and worse in the evening, but improves overnight)?

· Palpitations? Are they of sudden or gradual onset (cardiac arrhythmias are instantaneous, sinus tachycardia is slow onset)? Are they associated with pain, dyspnoea or faintness? Ask patient to tap out beat.

· Syncopal episodes (episodes of fainting)? Do they occur when standing up suddenly? Ask about anti-anginal and antihypertensive drugs that may cause postural hypotension. Do they occur with exertion?

· Intermittent claudication?

· Fatigue?

· Anorexia?

· Weight loss?

· Fever?

· PMH:

· Smoker?

· Heart attack? Other heart problems? (IHD)

· Hypertensive? (IHD)

· Lipid profile? (IHD)

· Diabetic? (IHD)

· Trauma? (pancreas)

· Gallstones? (choledocholithiasis)

· Asthma? (eosinophilic oesophagitis)

· Reflux? (GI)

· Ulcers? (GI)

· Pancreatitis? (GI)

· Recent long-distance travel or other long period of immobilization?

· Previous surgery? To abdomen? (cholecystectomy, pancreatectomy)

· Previous gastroscopy/colonoscopy?

· Medication:

· NSAIDs? Aspirin? Alcohol? à all potential causes of gastritis

· Alcohol consumption? (pancreas)

· Any recent changes to medications?

· FH:

· Cancer?

· Cardiac disease?

1. Questions to ask all the time:

· Smoker?

· Appetite?

· Weight loss?

· Any recent changes to medications?

· Allergies?

· Diabetic?

Differential Diagnoses:

CV aetiologies:

• AMI
• Aortic dissection
• Angina
• Pericarditis

Pulmonary aetiologies

• PE
• Pneumonia
• Pneomothorax
• COPD/Asthma exacerbation
• Lung cancer

Gastrointestinal aetiologies

• GORD
• Gastritis – pain not associated with dyspnoea or exertion, and not very severe
• Peptic ulcer disease – chronic pain assoc/w food; lasts hours-days
• Oesophageal spasm/eosinophilic oesophagitis/achalasia
• Pancreatitis
• Cholecystitis/choledocholithiasis
• Acute Hepatitis

Musculoskeletal aetiologies