Chest Pain: History Taking and Differential Diagnoses

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History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Chest pain

Use SOCRATES:

  • Site – where is the chest pain?
  • Onset – when did it start?
    • Was it sudden or gradual?
  • Character – how would they describe it? (e.g. sharp, crushing, stinging, burning)
  • Radiation:
  • Associated symptoms:
  • Exacerbating factors:
    • Breathing in, lying down, coughing, on exertion
  • Relieving factors:
    • Stopping exertion, sitting upright
  • Severity:
    • On a scale of 0-10?
  • Has it ever happened before?

Review of systems

  • Ask about systemic symptoms and red flags for malignancy:
    • Unexplained weight loss, night sweats, fevers, anorexia
  • Ask about cardiorespiratory symptoms:
  • Ask about risk factors for venous thromboembolism:
    • Recent surgery, long-haul flights, immobilisation, family history of clotting problems, oral contraceptive pill, pregnancy

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Do they have any risk factors for cardiac disease?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?
    • Any family history of heart problems or sudden death?

Allergy History

  • Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
  • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Investigations

Overview

Key initial investigations:

  • ECG – should be done as soon as possible:
    • May show changes consistent with a cardiac disorder (e.g. STEMI)
  • Cardiac troponins:
    • If acute coronary syndrome suspected
  • Chest x-ray:
    • If respiratory disorders are suspected
  • Coronary angiography with percutaneous coronary intervention (PCI):
    • For STEMI or those with an NSTEMI and a Grace score >3%

Differential Diagnoses

Acute coronary syndrome (ACS)

  • A history may reveal:
    • Dull crushing or heavy chest pain, the pain may radiate to the jaw or upper limb
    • Associated nausea, vomiting, pallor, shortness of breath, and dizziness
    • Risk factors for ACS (e.g. hyperlipidaemia, diabetes mellitus, stroke etc.)
  • A physical exam may reveal:
    • Nothing – an examination may be normal in ACS
    • Tachycardia and hypotension if the patient is in shock
  • Investigations may reveal:
    • ECG:
      • ST segment elevation – STEMI
      • ST depression or T-wave inversion – NSTEMI or unstable angina
    • Troponins:
      • Elevated in STEMI and NSTEMI
      • Normal in unstable angina

Stable angina

  • A history may reveal:
    • Dull chest pain or discomfort that is relieved with rest
    • No associated nausea, vomiting, pallor, shortness of breath 
  • A physical exam may reveal:
    • Nothing – an examination may be normal
  • Investigations may reveal:
    • ECG:
      • No acute changes
    • Troponins
      • Not elevated
    • CT coronary angiography:
      • Confirms diagnosis

Pulmonary embolism (PE)

  • A history may reveal:
    • Acute pleuritic chest pain, shortness of breath, haemoptysis
    • Risk factors are present (e.g. immobilisation, surgery, combined oral contraceptive use, pregnancy, long-haul flights)
    • A swollen lower leg that might be red may be present
  • A physical exam may reveal:
    • Tachycardia
    • Hypotension may be present in a massive PE
  • Investigations may reveal:
    • ECG:
      • Sinus tachycardia
    • D-dimer:
      • May be elevated
    • Chest x-ray:
      • Normal
    • CTPA or V/Q scan if the patient has chronic kidney disease:
      • Confirms diagnosis

Arrhythmia

  • A history may reveal:
  • A physical exam may reveal:
    • An irregular pulse
  • Investigations may reveal:
    • ECG:
      • May identify the arrhythmia
    • Holter monitoring:
      • May identify the arrhythmia

Pericarditis

  • A history may reveal:
    • Pleuritic chest pain, pain worse when lying down and improves with sitting up
    • Associated dry cough
  • A physical exam may reveal:
    • Friction rub
  • Investigations may reveal:
    • ECG:
      • May show saddle-shaped concave ST elevation and PR depression
    • Chest x-ray:
      • Normal
    • Echocardiography:
      • May show effusion

Cardiac tamponade

  • A history may reveal:
  • A physical exam may reveal:
    • Beck’s triad:
      • Hypotension
      • Raised jugular venous pressure
      • Muffled heart sounds
    • Pulsus paradoxus – large drop in blood pressure during inspiration
  • Investigations may reveal:
    • ECG:
      • Electrical alternans
  • Requires urgent pericardiocentesis

Aortic dissection

  • A history may reveal:
    • Tearing chest pain that may spread to the back
    • Shortness of breath
  • A physical exam may reveal:
  • Investigations may reveal:
    • Chest x-ray:
      • Widened mediastinum
    • CT angiography – investigation of choice for stable patients:
      • May show a false lumen
    • Transoesophageal echocardiography (TOE) for unstable patients

Pneumothorax (non-tension)

  • A history may reveal:
    • Acute pleuritic chest pain, shortness of breath
    • A history of COPD or trauma
  • A physical exam may reveal:
    • Absent breath sounds, hyperresonance
    • No tracheal deviation
  • Investigations may reveal:
    • Chest x-ray:
      • Absent lung markings

Tension pneumothorax

  • A history may reveal:
    • Acute pleuritic chest pain, shortness of breath
    • A history of trauma
    • Shock
  • A physical exam may reveal:
    • Absent breath sounds, hyperresonance
    • Tracheal deviation
    • Tachycardia and hypotension
    • Distended jugular venous pressure
  • Investigations may reveal:
    • If suspected, urgent needle decompression should be performed – do not wait for imaging
      • A chest X-ray should not be waited for as this can delay treatment and lead to cardiac arrest

Acute cholecystitis

  • A history may reveal:
    • Right upper quadrant pain that radiates to the back or right shoulder
    • Nausea, vomiting, fever, anorexia
  • A physical exam may reveal:
    • Right upper quadrant tenderness halting inspiration (Murphy’s sign)
  • Investigations may reveal:

Acute pancreatitis

  • A history may reveal:
    • Epigastric or periumbilical pain that radiates to the back
    • Nausea
    • Alcohol consumption or gallstones
  • A physical exam may reveal:
    • Fever, tachycardia, hypotension
    • Cullen’s sign – periumbilical region bruising
    • Grey-Turner sign – flank bruising
  • Investigations may reveal:
    • Serum lipase/amylase
      • Usually >3 times the upper limit of normal
      • Pancreatitis can be diagnosed clinically if characteristic pain and lipase/amylase >3 times upper limit of normal 
    • Imaging:
      • Ultrasound imaging – assess aetiology (e.g. gallstones)
      • Contrast-enhanced CT scan – confirms diagnosis

Pneumonia

  • A history may reveal:
    • Cough (may be productive), fever, pleuritic chest pain, shortness of breath, rigors, myalgias
    • A history of foreign travel or exposure to a person with infection
  • A physical exam may reveal:
    • Decreased breath sounds, dullness to percussion, crackles 
  • Investigations may reveal:
    • Chest x-ray:
      • May show opacifications
    • Full blood count (FBC):
      • Leukocytosis and neutrophils
    • Sputum culture:
      • Identifies underlying agent
    • Blood cultures:
      • Identifies underlying agent

Gastro-oesophageal reflux disease (GORD)

  • A history may reveal:
    • Retrosternal chest pain that is worse with trigger foods (e.g. fatty meals, caffeine, alcohol, spicy foods)
    • Pain relieved by sitting up, using antacids
    • Regurgitation
  • Investigations may reveal:
    • Endoscopy (if NICE criteria met e.g. dysphagia, >55 years, weight loss): may identify tumour or ulcers
    • H. pylori testing – urea breath test
    • Trial proton pump inhibitor (PPI)

Peptic ulcer disease

  • A history may reveal:
    • Epigastric pain that is worse with eating (gastric ulcers) or better when eating (duodenal ulcers, but the pain may return 1-4 hours after eating)
    • Symptoms improve with antacids
  • A physical exam may reveal:
    • Epigastric tenderness
    • Anaemia if there is bleeding
  • Investigations may reveal:
    • H. pylori urea breath test:
      • May be positive
    • Oesophagogastroduodenoscopy:
      • Identifies lesions

Costochondritis

  • A history may reveal:
    • Chest wall pain in a focal area that may be triggered by sneezing, coughing, breathing in deeply
    • There may be a preceding injury
  • A physical exam may reveal:
    • Reproducible pain on chest wall palpation
  • Investigations may reveal:
    • None – clinical diagnosis

Anxiety/panic disorder

  • A history may reveal:
    • Anxiety, sweating, trembling, fear of dying, paraesthesia, choking sensation, dizziness
  • A physical exam may reveal:
    • Hyperventilation
  • Investigations are normal

Boerhaave syndrome (oesophageal rupture)

  • A history may reveal:
    • Repeated episodes of vomiting
  • A physical exam may reveal:
    • Chest wall subcutaneous emphysema
  • Investigations may reveal:
    • CT contrast swallow:
    • Confirms diagnosis

Shingles

  • A history may reveal:
    • Burning pain in a specific dermatome
    • Pain usually precedes a rash
  • A physical exam may reveal:
    • Vesicular, erythematous rash in a dermatomal distribution
  • Investigations may reveal:
    • None – clinical diagnosis

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