4 Chest Pain History taking PDF

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Summary

Asthma Michael Grant Asthma is seen as reversible obstruction due to bronchospasm from hyper responsive bronchi. Seen clinically as a wheeze, SOB and cough. It is usually linked to a type 1 hypersensitivity.• Divided into: o Extrinsic – most commonly involves a Type 1 hypersensitivity IgE component,...

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Chest Pain History APPROACH TO CHEST PAIN – HISTORY TAKING OSCE Taking a comprehensive chest pain history is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough chest pain history.

OPENING THE CONSULTATION Introduce yourself – name/role Confirm patient details – name/Age Explain the need to take a history Gain consent Ensure the patient is comfortable Presenting complaint It’s important to use open questioning to elicit the patient’s presenting complaint “So what’s brought you in today?” or “Tell me about your symptoms” Allow the patient time to answer, trying not to interrupt or direct the conversation. Facilitate the patient to expand on their presenting complaint if required. “Ok, so tell me more about that” “Can you explain what that chest pain was like?” History of presenting complaint Gain further details about the chest pain using SOCRATES Site – where is the pain (e.g. central chest) Onset: Duration of pain (important when considering angina vs acute coronary syndrome) Did it come on suddenly or has it been gradually building? What was the patient doing at the time of onset? (exertional / at rest) Character: Aching/crushing – typical of acute coronary syndrome (ACS) Sharp pain that’s worse on inspiration (pleuritic) – pulmonary embolus/pneumothorax Radiation: Does the pain move anywhere else?

Left arm and jaw is typical of ACS Radiation through to the back is associated with aortic dissection Associated symptoms: Dyspnoea – exertional? / orthopnea? / paroxysmal nocturnal dyspnoea? Sweating / clamminess / nausea – associated with ACS Cough – duration? / productive of sputum? (pneumonia) / haemoptysis? (PE) Palpitations – ask patient to tap out the rhythm Syncope / dizziness – postural? / exertional? / random? Oedema – peripheral oedema (e.g. lower limbs) Fever – pericarditis / costochondritis / pneumonia Time course: Duration – minutes / hours / days / weeks Worsening / improving / fluctuating Exacerbating/relieving factors: Does anything make the pain worse? Inspiration (PE / pneumothorax / pneumonia) Exertion (ACS / PE / pneumothorax / pneumonia) Lying flat (pericarditis) Does anything make the pain better? GTN spray (ACS or oesophageal spasm) Leaning forward (pericarditis) Severity – on a scale of 0-10 how severe is the pain? Has the patient had chest pain like this before? If the patient has angina, is this pain similar or different? Ideas, Concerns and Expectations Ideas – what are the patient’s thoughts regarding their symptoms? Concerns – explore any worries the patient may have regarding their symptoms Expectations – gain an understanding of what the patient is hoping to achieve from the consultation Summarising Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding regarding everything the patient has told you. It also allows the patient to correct any inaccurate information and expand further on certain aspects. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting Signposting involves explaining to the patient: What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them” What you plan to cover next – “Now I’d like to discuss your past medical history and your medications” Past medical history Cardiovascular disease: Angina Myocardial infarction – bypass grafts / stents Hypertension Hyperlipidaemia Aortic aneurysm / dissection Respiratory disease: Pneumonia Pneumothorax Pulmonary embolus Gastrointestinal disease: Gastro-oesophageal reflux Oesophageal spasm Other medical conditions Surgical history – bypass graft / stents / valve replacements Acute hospital admissions – when and why? Drug history Regular prescribed medication Antiplatelets or anticoagulants GTN spray Contraceptive pill – increased risk of thromboembolic disease (e.g. PE) Over the counter drugs Herbal remedies ALLERGIES – ensure to document these clearly

Family history

Cardiovascular disease at a young age – myocardial infarction / hypertension / thrombophilia/sudden death/stroke Are parents still in good health? – if deceased sensitively determine age and cause of death Social history Smoking – How many cigarettes a day? How many years have they smoked for? Alcohol – How many units a week? – type / volume / strength of alcohol Recreational drug use – e.g. Cocaine – coronary artery vasospasm Diet – obesity/fat and salt intake – cardiovascular risk factors Exercise – baseline level of patient’s day to day activity Living situation: House/bungalow? – adaptations / stairs Who lives with the patient? – is the patient supported at home? Any carer input? – what level of care do they receive? Activities of daily living: Is the patient independent and able to fully care for themselves? Can they manage self-hygiene/housework/food shopping? Occupation – sedentary jobs increase cardiovascular risk – e.g. lorry driver Systemic enquiry Systemic enquiry involves performing a brief screen for symptoms in other body systems. This may pick up on symptoms the patient failed to mention in the presenting complaint. Some of these symptoms may be relevant to the diagnosis (e.g. fever in pericarditis). Choosing which symptoms to ask about depends on the presenting complaint and your level of experience. Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion Musculoskeletal – Bone and joint pain / Muscular pain Dermatology – Rashes / Skin breaks / Ulcers / Lesions Closing the consultation Thank patient Summarise history Differential diagnoses of chest pain

Below is a selection of differential diagnoses that can present with chest pain, with included typical presenting patterns. Cardiovascular Acute coronary syndrome: Central crushing chest pain Radiating to left arm/jaw Duration of more than 20 minutes Associated with sweating/clamminess/nausea/shortness of breath Symptoms are often worsened by exertion and improved with GTN spray Stable angina: Central chest pain Radiating to left arm/jaw Duration less than 20 minutes with full resolution Often triggered by exertion and resolved with GTN spray/rest Associated with shortness of breath Pericarditis: Central chest pain Worsened by lying flat and improved by leaning forwards Patient may have had multiple episodes in the past Aortic dissection: Central chest / abdominal pain Radiating through to the back “Tearing” in nature May have associated syncope/dizziness due to haemodynamic instability Respiratory Pneumonia: Sharp chest pain worsened by inspiration (pleuritic) Associated cough, shortness of breath, fever and malaise Spontaneous pneumothorax: Sudden onset sharp chest pain Pleuritic in nature Shortness of breath Pulmonary embolism: Sudden onset chest pain Shortness of breath Haemoptysis (rare)

Gastrointestinal Gastro-oesophageal reflux: Epigastric / chest pain Burning in nature Worsened by lying flat Oesophageal spasm: Epigastric / central chest pain Relieved by GTN spray (hence can be confused with ACS) No associated shortness of breath

CASE SCENARIO WHO PRESENT WITH CHEST PAIN Case 1-CVS New onset angina (ACS) A 65-year-old Malay male, currently pain-free but experienced chest pain in the previous 12 hours Presentation to A&E HTAA: Haji Muhammad, 65 years old, presents to you at 0830. He reports that he had chest pain last night, which woke him from his sleep. The pain started at around 0200. He thinks it lasted about 20–25 minutes. He reports that he felt sweaty during the pain. He did not want to bother anyone so he rested and the pain eased. He reports that it was very painful and therefore went to A&E for further evaluation. He is currently not in any pain, although he feels quite tired. Case 2-CVS Chronic stable angina A 72-year-old female, who experienced chest pain 3 days ago while walking Presentation to MOPD: Yogeswary is a 72-year-old female who reports experiencing chest pain 10 days ago while she was out walking. Her chest and left shoulder felt tight. She stopped walking and rested and the pain eased. She did not seek medical help at the time because she thought it was a stitch. She then experienced the same pain while out walking 3 days ago, which stopped when she sat down. Case 3 – Respiratory-Pneumonia with pleuritis A 66-year-old male presented to an urgent care clinic with a 4-day history of dry cough, progressing to rusty colored sputum, sudden onset of chills the previous evening, subjective fever, and malaise. Originally, the man thought he had a cold, but the symptoms had worsened and he “barely slept last night with all this coughing.” He denied experiencing shortness of breath but suggested he may be breathing “a little faster than normal.” He related that, on the way to the clinic, he felt some sharp right-sided

chest pain after a particularly long bout of coughing. He denied any leg swelling, orthopnea, or left-sided/substernal chest pain. He also denied any gastrointestinal symptoms (no nausea, vomiting, or diarrhea). His past medical history included hypertension and hypercholesterolemia. He reported no antibiotic use in the previous three months. Case 4- Respiratory- spontaneous pneumothorax A 24-yr-old Caucasian female was evaluated in May, 2003 at the San Martino hospital, Genoa, Italy,

for the presence of “sudden onset” chest pain and nonproductive cough. Past medical history was only characterised by the presence of frequent headaches. The patient had been playing competitive tennis from the age of 6–20 yrs and, after retirement from competitions, had been smoking cigarettes (0.5 pack·day−1) for the last 4 yrs. The patient was nulliparous and reported the use of oral contraceptive in the last 3 yrs. Any suggestion of respiratory symptoms, including cough, shortness of breath or physical limitations during exercise were denied. On admission, the patient had no dyspnoea, and physical examination demonstrated a slight decrease in breath sounds over the left hemithorax. Heart sounds were normal and there was no cyanosis, clubbing or oedema. The abdomen was nondistended, nontender, and without bruits, hepatosplenomagaly or masses. There were no focal neurological findings. The patient had normal body temperature with normal values of blood pressure, pulse and respirations and transcutaneous blood gas determination in room air showed normal arterial oxygen and carbon dioxide tension.

Case 5- Respiratory- pulmonary embolism A 25 year old Malay female reports to the Emergency Room because of sharp left sided chest pain and shortness of breath of one day duration. The patient was in excellent health until yesterday. She was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and deep breathing. The pain has been progressively increasing in severity and she now has severe left shoulder pain. She complains of shortness of breath and is very apprehensive about dying. She denies any cough, fever, sputum production or hemoptysis. She is married and had one normal delivery three years ago. She is currently on birth control pills. She has never been hospitalized except for labor and delivery. Review of systems are negative. She denies any past history of venous problems. She reveals having a similar transitory minor episode of chest pain approximately one year ago while she was vacationing in oversea. She works as a computer programmer. She non-smoker. She has a family member with SLE. Case 6- GIT- oesophageal spasm A 52 year old female, a college teacher, presented in the out patient department, with 3 years history of severe crushing chest pain usually after meals and sometimes on empty stomach, necessitating frequent emergency check-ups. She also gave history of dysphagia for both solids and liquids and regurgitation of food with vomiting.

Case 7- CVS- dissecting aortic aneurysm A 73-year-old man presented to the ED complaining of chest pain and shortness of breath. The pain was in the left anterior chest and left flank and ocassionally radiating to the back. He had a nonproductive cough and slight wheezing. He had had the pain intermittently for 1 week. It had become more severe in the past few hours and was associated with vomiting. He had a history of COPD and hypertension for 7 years....