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:
- Jaw, left arm, and back – myocardial infarction
- Towards the back – dissection
- Associated symptoms:
- Shortness of breath, cough, fever, nausea, sweating, light-headedness
- 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:
- Palpitations, shortness of breath, cough, haemoptysis, oedema, paroxysmal nocturnal dyspnoea, orthopnoea
- 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?
- Coronary heart disease, angina, myocardial infarction?
- Stroke, deep vein thrombosis, pulmonary embolism?
- High blood pressure?
- Diabetes mellitus?
- 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
- ECG:
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
- ECG:
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
- ECG:
Arrhythmia
- A history may reveal:
- Palpitations, chest pain, syncope
- A physical exam may reveal:
- An irregular pulse
- Investigations may reveal:
- ECG:
- May identify the arrhythmia
- Holter monitoring:
- May identify the arrhythmia
- ECG:
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
- ECG:
Cardiac tamponade
- A history may reveal:
- Shortness of breath and fatigue
- 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
- Beck’s triad:
- Investigations may reveal:
- ECG:
- Electrical alternans
- ECG:
- 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:
- Unequal pulses or blood pressures in both arms
- Diastolic murmur – aortic regurgitation
- 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
- Chest x-ray:
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
- Chest x-ray:
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
- If suspected, urgent needle decompression should be performed – do not wait for imaging
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:
- Liver function tests:
- Elevated ALP and GGT
- Full blood count:
- Leukocytosis
- Ultrasound scan:
- Confirms diagnosis
- Liver function tests:
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
- Serum lipase/amylase
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
- Chest x-ray:
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
- H. pylori urea breath test:
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