Michael Smith, a 55-year-old man came to the clinic complaining of chest discomfort that has lasted for the past hour. Perform a focused history and physical examination. His vital signs are as follows: blood pressure 160/90 mm Hg, heart rate 96/min, respiratory rate 20/min, and temperature 37.5°C.

History of present illness

  • Onset/Setting: What were you doing? How did you come to the clinic today? If by ambulance- Did they give you aspirin/nitrates? Did it help you? (Non-cardiac pain is often relieved with Nitroglycerin e.g. Esophageal Spasm)
  • Position: Where did it start? Can you point with one finger at it?
  • Quality: How does it feel like? (sharp, dull, pressure, tightness, tearing). Severity of pain on a scale of 1-10.
  • Radiation: Does it shoot anywhere? Your jaw, your shoulders, your back?
  • Associations: Is the chest pain associated with breathing? Anything that provokes it? (e.g. walking or other physical exertion, deep breathing, eating, torso movement, direct pressure)

Review of symptoms

  • Cardiac: Nausea/vomiting, sweating/feeling tired, shortness of breath? How many pillows do you use? Do you wake up gasping for air? Dizzy/ lightheadedness? Are you tired? Any swelling in your legs? How high does it go? Is it related to position? Eye puffiness? Pain on the liver?
  • Pulmonary: Any cough or phlegm? Chest tightness? Wheezes? Recent fever/flu-like symptoms? Muscles/ joint pain?
  • Gastro: Difficulty swallowing (esophageal spasm), heartburn/acidic taste in your mouth?
  • Chest wall: Any trauma, blisters/skin rash on the skin
  • DVT: Any pain/swelling/redness in your legs/calves? Any recent long travel?

Past medical/surgical history

  • High blood pressure? High blood sugar? High cholesterol: have you got your cholesterol measured before?
  • Past history of stroke? Symptoms of stroke (weakness/numbness/change in vision/ difficulty finding words)?
  • Any history of peptic ulcer disease, reflux, or GERD?
  • Female: pregnancy / OCPs / HRT
🔺 RED FLAGS: Tearing severe chest pain radiating to back (Aortic dissection), Angina-like pain not relieved by NTG (unstable angina/MI), Syncope/pre-syncope (hypotension), dyspnea at rest (PE/pneumothorax), pleuritic chest pain or hemoptysis (Pulmonary embolism).
🔺 Chest tightness with radiation to the left arm, jaw, and/or back that is associated with dyspnea should be considered cardiac chest pain until proven otherwise.

Social / Family history

  • Family history of a heart attack at age < 50 yrs
  • Smoking / Cocaine

Patient Encounter Probe

Chest pain is a very common clinical presentation with a spectrum of underlying causes ranging from benign to life-threatening.