History Taking : Chest Pain

History taking Scenario

Your Role :

You are the medical SHO /RMO on call clerking in A & E and are asked to assess a young man with chest pain.

Your patient : T L , age 21

This young man presents with chest pain.He has been out clubbing with his friends on Saturday night and developed sudden onset of retrosternal chest pain radiating to the back with associated shortness of breath.

His father suffered from an MI at age of 50 years.

He is concerned that he is having an MI.

His Chest X ray shows a pleural effusion on right side.

The ECG shows a Sinus Tachycardia but is otherwise un remarkable.

Blood Tests are awaited.

Please take a detailed history from this patient keeping in mind the major differential diagnoses.

Main points and approach to the scenario:

Greet the examiners

Read the scenario carefully with focus on patients name ,age and presenting complaint.

Assess/ determine what is being asked from you in the scenario.

Take time to read the scenario fully in the required time frame.

Asssess the time you have to complete a focused and clear history and make sure you rule out the main alarming conditions first that present with chest pain.

For example in this scenario , Set Your objectives

You have to take a focused and comprehensive History to exclude the conditions below :

Differential Diagnosis:

Esophageal Rupture
Pulmonary Embolism
Aortic Dissection
Acute Myocardial Infarction
GORD : Gastroesophageal reflux disease
Acute Pancreatitis
Pneumothorax

Now Greet the patient and Introduce Yourself

History Of Present Illness

Take a detailed account of history of present illness following the format:

ODPARRA:

Onset
Duration
Progression
Associated Factors
Relieving Factors
Radiation
Aggravating Factors

Here is how to begin this station

Good Morning Mr L

My name is Dr AR and I am here to ask you a few questions to better understand the casue of your coming to the hospital today

Is it alright if I proceed?

Are you feeling comfortable ?

The above questions are important to ask as they constitute an important score in exam which is called Maintaining Patients Welfare.

So can you please tell me in your own words what brought you to hospital today ?

Listen carefully to what patients says noting any new points that were not present in patients history.

Onset :
Can you please tell how did the problems start?

Was it sudden in onset or have you been feeling it for some time and it got accentuated?

Duration:

How long this stay for.

Over what period of time did this happen.

If repetitive problem ,how long has this been happening ?

Is it constant or intermittent ?

Progression:

Did it get worse? Stayed the same ? or improved ?

Associated Factors :

Any nausea ,sweating , fever , vomiting ,sob : Cardiac

PND , orthopnea ,ankle oedema : Left ventricular failure.

Abdominal pain ?

Any trauma to chest etc

Any cough haemoptysis : PE and LRTI

Any unilateral swelling of leg DVT.

Any recent history of travel abroad ?

Cold/flu like symptoms : Pericarditis

Excessive drinking before the episode : Esophageal perforation

Radiation:

Any radiation of the pain somewhere eg back etc,

Aortic dissection, pancreatitis and peptic ulcer radiate to the back.

Cardiac ischaemic pain radiates to left jaw,neck and left arm.

Nerve root pain remains around the chest wall in a band like pattern.

Relieving factors :

Any thing that made it better eg medication , change in position etc

Analgesics : Musculoskeletal pain

Cardiac pain : rest and nitrates.

Antacids : GORD and PUD.

Aggravating Factors :

Any thing that made it worse?

Deep inspiration : pericarditis and respiratory.

Movement : Musculoskeletal.

Eating / after meals : peptic ulcer disease and GORD.

Bending forward : pericarditis.

Exertion ? Cardiac.

Family History of IHD , Hypercholesterolemia , Angina , Asthma ,MI , Hypertension , Epilepsy or bleeding disorders

Site of chest pain”

Cardiac : central and often radiates to left jaw neck and left arm.Is brought with exertion and may be associated with shortness of breath.

Respiratory : is usually present on site of pathology eg infection or pneumothorax.

Musculoskeletal : is present at site of pathology or injury

Peptic ulcer disease / GORD occurs in lower chest and epigastrium.

Nature of pain :

Cardiac / ischemic : Dull pressure like sensation.

Pericarditis and Respiratory : sharp and pleuritic.

Nerve root pain : band like shooting pain around the chest from the back to the front.

GORD : sharp and burning

Personal History

Any habitual smoking or drinking alcohol ?

Past Medical and Family history :

Cardiovascular risk factors :

Smoking , hypertension,diabetes,hypercholesterolemia and family history of these.

Any compliance to treatment

Previous MI or CABG / BYPASS etc

History of clotting / thrombotic disorders

Medications and their compliance

Occupational history

Assess the disability and impact on life

Address the patients concerns about this

Plan of Management :

Tell the patient the most likely Differental Diagnosis and other possible causes

In this case this seems like an Esophageal perforation but other D/D are:

Pulmonary Embolism
Aortic Dissection
Acute Myocardial Infarction
GORD : Gastroesophageal reflux disease
Acute Pancreatitis
Pneumothorax
Pleurisy
Pneumonia
Pericarditis

Further investigations will be needed to ascertain the cause eg

Chest X ray
ECG
Oxyge saturations
Full Blood Count
D- dimers
Arterial Blood gases
CTPA