Opening the consultation Introduce yourself – name / role Confirm patient details – name / DOB 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 1. Site – where is the pain (e.g. central chest) 2. 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) 3. Character: Aching / crushing – typical of acute coronary syndrome (ACS) Sharp pain that’s worse on inspiration (pleuritic) – pulmonary embolus / pneumothorax 4. 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 5. 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 6. Time course: Duration – minutes / hours / days / weeks? Worsening / improving / fluctuating? 7. Exacerbating / relieving factors: Anything make the pain worse? Inspiration (PE / pneumothorax / pneumonia) Exertion (ACS / PE / pneumothorax / pneumonia) Lying flat (pericarditis) Anything make the pain better? GTN spray (ACS or oesophogeal spasm) Leaning forward (pericarditis) 8. Severity – on a scale of 0-10 how severe is the pain? 9. 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 1. Cardiovascular disease: angina Myocardial infarction – bypass grafts / stents Hypertension Hyperlipidaemia Aortic aneurysm / dissection 2. Respiratory disease: Pneumonia Pneumothorax Pulmonary embolus 3. Gastrointestinal disease: Gastro-oesophageal reflux Oesophageal spasm 4. Other medical conditions 5. Surgical history – bypass graft / stents / valve replacements 6. 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 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 – Overweight? Fatty foods? 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. reduced urine output in dehydration). 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. 1. 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 2. 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) 3. 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 Source
