Quick Revise
Background
Chest pain is one of the most common and most important presenting complaints in clinical practice. It can range from benign musculoskeletal pain to immediately life-threatening emergencies such as acute coronary syndrome (ACS), pulmonary embolism, aortic dissection, or tension pneumothorax.
For medical students, chest pain is a high-yield OSCE station because it tests your ability to:
- Take a structured and focused history using SOCRATES.
- Recognise red flags that require urgent intervention.
- Differentiate between cardiac, respiratory, gastrointestinal, musculoskeletal, and psychological causes of symptoms.
Examiners are looking for students who can prioritise dangerous causes, gather relevant risk factors, and summarise findings logically. A clear and confident approach not only scores well in exams but also reflects safe clinical practice on the wards.
Common Causes of Chest Pain
| System | Condition | Key Features |
|---|---|---|
| Cardiac | Acute coronary syndrome (MI/unstable angina) | Central, crushing pain ± radiation to jaw/arm, sweating, nausea |
| Stable angina | Exertional, relieved by rest/GTN, short duration | |
| Pericarditis | Sharp, pleuritic, worse lying flat, relieved sitting forward | |
| Aortic dissection | Sudden onset, tearing pain radiating to the back, unequal pulses | |
| Respiratory | Pulmonary embolism (PE) | Sudden pleuritic pain, SOB, haemoptysis, risk factors (surgery, immobility) |
| Pneumonia | Pleuritic pain, fever, cough, sputum | |
| Pneumothorax | Sudden unilateral pleuritic pain, SOB, hyperresonance, ↓ breath sounds | |
| GI | Gastro-oesophageal reflux (GORD) | Retrosternal burning, worse on lying/after meals, relieved by antacids |
| Oesophageal spasm | Retrosternal squeezing, mimics angina, may be meal-related | |
| Peptic ulcer disease | Epigastric pain may radiate to the chest, related to meals | |
| MSK | Costochondritis | Localised, reproducible on palpation, sharp |
| Rib fracture / muscle strain | Post-trauma, local tenderness, worse with movement | |
| Psychological | Panic attack/anxiety | Panic attack/anxiety |
Opening the Consultation
- Wash your hands, introduce yourself, confirm patient details and gain consent.
- If acutely unwell → prioritise ABCDE and urgent help.
- Ask an open question: “Can you tell me more about your chest pain?”
Presenting Complaint
- Start with an open-ended question:
“Can you tell me more about the chest pain that brought you in today?” - Allow the patient to describe the symptom in their own words before you guide them with structured questions.
- When documenting:
- Write it as: “Chest pain for [duration]”
- If intermittent: “Intermittent chest pain for [timeframe]”
- If ongoing: “Ongoing chest pain for [x hours/days]”
- Clarify the main symptom:
- Some patients might use terms like “tightness,” “pressure,” “burning,” or “discomfort” rather than “pain.”
- Ensure you accurately record the word they use, as it may guide your differential (e.g., “tightness” → cardiac, “burning” → GORD).
💡 OSCE Tip
Examiners often look for whether you capture the complaint in a clear, concise format (symptom + duration). Avoid writing vague entries like “chest problem.”
ICE (Ideas, Concerns, Expectations)
System Enquiry
A targeted system enquiry ensures you don’t miss related symptoms that point towards specific differentials.
- Dyspnoea on exertion → angina, ACS, heart failure
- Orthopnoea → LV failure
- Paroxysmal nocturnal dyspnoea (PND) → heart failure
- Palpitations → arrhythmia, ACS
- Syncope or presyncope → arrhythmia, severe aortic stenosis, ACS
- Ankle swelling → heart failure, pericardial disease
- Cough ± sputum → pneumonia, bronchitis
- Haemoptysis → PE, lung cancer, pneumonia
- Pleuritic chest pain → PE, pneumonia, pleuritis
- Wheeze → asthma, COPD exacerbation
- Sudden shortness of breath → PE, pneumothorax
- Heartburn / retrosternal burning → GORD, oesophagitis
- Acid reflux / regurgitation → GORD
- Dysphagia → oesophageal spasm, stricture, malignancy
- Epigastric pain after meals → PUD, gastritis, gallstones
- Fever → pneumonia, pericarditis, myocarditis, sepsis
- Night sweats → TB, lymphoma, chronic infection
- Weight loss → malignancy, chronic GI disease
- Fatigue → anaemia, chronic disease
- Anxiety/panic symptoms (palpitations, hyperventilation, sense of doom) → panic disorder
💡 OSCE Tip
Examiners expect you to link chest pain + associated system enquiry to specific differentials (e.g., chest pain + orthopnoea → think LV failure”).
Past Medical History
Asking about past medical history is crucial because many chronic conditions predispose to SOB:
- Ischaemic heart disease → risk of ACS/angina
- Heart failure → chest pain + dyspnoea/orthopnoea
- Arrhythmias → palpitations, syncope, chest discomfort
- Valvular disease (esp. aortic stenosis, mitral valve disease) → angina, syncope, heart failure
- Hypertension → major risk factor for ACS, dissection
- Asthma / COPD → can present with chest tightness or breathlessness
- Previous PE or DVT → risk of recurrence
- Interstitial lung disease / TB → chronic chest pain or cough
- Gastro-oesophageal reflux disease (GORD) → burning retrosternal pain
- Peptic ulcer disease → epigastric pain radiating to the chest
- Gallstones → biliary colic, referred chest/epigastric pain
- Diabetes mellitus → silent ischaemia, ACS risk
- Hyperlipidaemia → coronary artery disease risk
- Connective tissue disorders (e.g. Marfan’s, Ehlers–Danlos) → predispose to aortic dissection
- Anaemia → can worsen angina or mimic chest discomfort
- Chronic kidney disease → uraemic pericarditis, fluid overload
Surgical History
Past surgery can be related to chest pain as:
- CABG (coronary artery bypass graft) – recurrent angina, graft disease
- PCI / stents – risk of restenosis, recurrent chest pain
- Valve surgery/replacement – endocarditis, prosthetic valve thrombosis
- Pacemaker / ICD insertion – procedural complications, local discomfort
- Lobectomy/pneumonectomy – reduced lung capacity, chronic chest pain
- Thoracic trauma surgery – adhesions, scarring, MSK pain
- Fundoplication / bariatric surgery – GORD-related pain, post-op issues
- Cholecystectomy – biliary-type pain history pre-surgery
- Major surgery / prolonged immobilisation – risk of DVT/PE
- Splenectomy – infection risk → sepsis presentations with chest pain
💡 OSCE Tip
If the patient has had a recent surgery, always consider PE as a differential diagnosis.
Drug History
| Drug Class | Examples | Relevance to Chest Pain |
|---|---|---|
| Anti-anginals | GTN spray, beta-blockers, calcium channel blockers, ranolazine | Suggests known IHD; ask if GTN relieves pain (angina clue) |
| Antiplatelets / Anticoagulants | Aspirin, clopidogrel, warfarin, DOACs | Previous ACS, stents, stroke; ↑ bleeding risk if thrombolysis considered |
| Statins | Atorvastatin, simvastatin | Secondary prevention of IHD |
| ACE inhibitors / ARBs | Ramipril, losartan | Cardiovascular risk factor management |
| Diuretics | Furosemide, spironolactone | Heart failure history; electrolyte disturbances may cause arrhythmia |
| NSAIDs | Ibuprofen, naproxen | Can cause gastritis, peptic ulcer → chest/epigastric pain |
| Steroids | Prednisolone | Long-term use → osteoporosis, immunosuppression, GORD |
| Chemotherapy / Radiotherapy | Doxorubicin, chest radiotherapy | Previous ACS, stents, stroke; ↑ bleeding risk if thrombolysis is considered |
💡 OSCE Tip
Examiners love it when you link the drug back to the condition (e.g., patient on GTN spray → likely angina/IHD).
Allergies
- Always ask: “Do you have any allergies to medications or substances?”
- Penicillin allergy → relevant if pneumonia suspected (limits antibiotic choice).
- Contrast media allergy → important if CT-PA or coronary angiography is needed.
- NSAID allergy → may limit analgesia; also relevant in patients with asthma (NSAID-induced bronchospasm).
- Always document the nature of the reaction (rash, angioedema, anaphylaxis).
💡 OSCE Tip
Examiners expect you to not just record “allergic” but also ask what happened (e.g., rash vs anaphylaxis).
Family History
- When taking a family history, focus on conditions that increase cardiac or thromboembolic risk:
- Premature ischaemic heart disease (IHD) → MI or angina in first-degree relative (<55 men, <65 women).
- Sudden cardiac death → may suggest inherited arrhythmias (e.g., long QT, HCM).
- Clotting disorders → family history of DVT/PE (e.g., Factor V Leiden, Protein C/S deficiency).
- Familial hypercholesterolaemia → strong risk factor for premature CAD.
- Aortic disease → Marfan’s or other connective tissue disorders (risk of dissection).
💡 OSCE Tip
Always specify first-degree relatives (parents, siblings, children). Examiners often give marks for asking about premature IHD in particular.
Social History
- Ask: “Do you smoke? If so, how many per day and for how long?”
- Document in pack-years.
- Smoking is a major risk factor for IHD, PE, lung cancer, and COPD.
- Ask about vaping or nicotine replacement therapy if they’ve quit.
- Ask: “How much alcohol do you drink in a typical week?” (units/week).
- Heavy use → alcoholic cardiomyopathy, arrhythmias (AF), GORD.
- Note any binge patterns (linked to acute arrhythmias).
- Stressful jobs → ↑ risk of ACS.
- Manual labour → MSK chest pain.
- Asbestos exposure → pleural disease, mesothelioma.
- Coal mining, construction, farming → lung disease risk.
- “How far can you walk before chest pain or breathlessness?”
- Helps assess the severity of angina/heart failure.
- Functional status is important for discharge planning.
- Who do they live with? Carer involvement?
- Relevant for planning if admitted with ACS/heart failure.
💡 OSCE Tip
Examiners expect you to always cover smoking & alcohol — these are easy marks. Mentioning occupation & function often gets you bonus credit for being thorough.
Travel History
- Always ask about recent travel or immobility — particularly if chest pain is sudden and pleuritic.
- Recent long-haul flights or prolonged immobility → risk of DVT/PE.
- TB endemic areas → consider tuberculosis, which can rarely cause chest pain (pleural involvement).
- Recent infectious exposures → COVID, influenza → viral myocarditis, pericarditis, pneumonia.
- Occupational/migrant history → exposure to asbestos, silica, coal dust (if not already covered in occupation).
💡 OSCE Tip
Examiners often use travel history as a hidden clue for PE. Don’t forget to ask!
Closing the Consultation
- When finishing your history, always summarise, check understanding, and outline the next steps.
- Summarise the key points back to the patient
- “So, you’ve told me you’ve been experiencing chest pain that started suddenly yesterday, it’s central and crushing, and it came on while you were resting…”
- Check the patient’s understanding and invite questions
- “Does that sound correct to you? Is there anything important I’ve missed?”
- “Do you have any questions or worries about what we’ve discussed so far?”
- Explain what happens next
- Examination (cardiac and respiratory exam).
- Bedside investigations (ECG, observations, troponin, bloods, CXR).
- Further management depending on findings (e.g., urgent cardiology referral if ACS suspected).
- Close politely
References
- Oxford Handbook of Clinical Medicine, 10th Edition – Chest Pain & Cardiovascular Sections
- NICE Clinical Knowledge Summaries (CKS):
- BMJ Best Practice: Chest Pain Evaluation & Management
- RCGP eGuidelines: Cardiovascular presentations in primary care
