Clerking chest pain

History

In clerking chest pain, it is best practice to first rule out acute myocardial ischaemia before exploring other possible causes. The structure of the history is as follows:

Obtain the patient’s biodata, taking note of the age especially.

With the mnemonic ‘SOCRATES’ as a guide, ask about the following to characterise the pain:

  • Site of the pain; whether the pain is localised or diffuse
  • Onset of the pain; whether sudden or gradual
  • Character of the pain: dull, burning, sharp or stabbing
  • Whether the pain Radiates to any part of the torso
  • Associated symptoms like coughing, breathlessness
  • Timing of the pain; whether worse at any time, continuously present, or intermittently with pain-free periods in between.
  • Exacerbating and relieving factors
  • Severity of the pain, usually using a pain scale

More specific questions may then be asked as follows depending on the possible differentials already generated after characterising the pain. 

Common differentials:

  • Acute coronary syndrome: 

central chest pressure, squeezing, or heaviness; radiation to jaw or upper extremities; associated nausea, vomiting, dyspnoea, dizziness, weakness; occurs at rest or accelerating tempo (crescendo); risk factors: smoking, age (men >45, women >55 years), positive FHx of premature CAD, hypertension, hyperlipidaemia, diabetes, stroke, or peripheral arterial disease

  • Stable angina:

known history of coronary artery disease; chest discomfort on exertion; no change in intensity, frequency, or duration; associated diaphoresis, nausea/vomiting, or shortness of breath; risk factors: smoking, age (men >45, women >55 years), positive family history of premature CAD, hypertension, hyperlipidaemia, diabetes, stroke, or peripheral arterial disease

  • Pulmonary embolism:

sharp and pleuritic in nature; shortness of breath; haemoptysis may occur if pulmonary infarction develops; massive PE results in syncope; risk factors: history of immobilisation, orthopaedic procedures, oral contraceptive use, previous PE, hypercoagulable states, or recent travel over long distances; unilateral swollen lower leg that is red and painful suggests DVT; use of the modified Wells criteria can help to screen for risk factors and clinical features suggesting high probability

  • Pneumonia:

productive or dry cough, fever, pleuritic pain associated with shortness of breath; may have rigors, myalgias, and arthralgias; recent history of travel or infectious exposures

  • Viral pleuritis:

prodrome of viral illness (myalgias, malaise, rhinorrhoea, cough, nasal congestion, low-grade temperatures); sick contacts

  • Gastro Oesophageal Reflux Disease:

retrosternal burning with eating large or fatty meals that can be reproduced with lying supine and relieved by sitting up; relieved by antacids

  • Costochondritis:

focal chest wall pain, may have known precipitating injury; aggravated by sneezing, coughing, deep inspiration, or twisting of the chest

  • Anxiety or panic disorder:

sharp chest pain with anxiety, dizziness or faintness, palpitations, sweating, trembling or shaking, fear of dying or going insane, paraesthesiae, chills or hot flushes, breathlessness or choking sensation

Uncommon

  • Pericarditis:

usually has viral prodrome; sharp pleuritic chest discomfort provoked by lying supine and improved with sitting up; associated dry cough, fever, myalgias, or arthralgias; history of possible causes such as radiation exposure, collagen vascular disease, recent MI, or uraemia

  • Cardiac tamponade: 

history of underlying cause such as MI, aortic dissection, or trauma; may present insidiously as a result of hypothyroidism or pericarditis; dizziness; dyspnoea; fatigue

  • Aortic dissection:

acute substernal tearing sensation, with radiation to interscapular region of the back; pain may migrate with the propagation of the dissection; stroke, acute MI due to obstruction of aortic branches; dyspnoea due to acute aortic regurgitation; hypotension due to cardiac tamponade; history of hypertension, Marfan’s syndrome, Ehlers-Danlos syndrome, or syphilis

  • Aortic stenosis:

age over 60 years; typical angina; chest pain is usually progressive; shortness of breath; syncope (if severe); patients with significant aortic stenosis and heart failure are at high risk of cardiogenic shock or sudden death

  • Mitral valve prolapse:

usually asymptomatic, but may cause palpitations, chest pain, dyspnoea, headache, or fatigue

  • Pneumothorax:

acute, pleuritic chest pain, shortness of breath; primary spontaneous between ages 20 and 40 years; secondary spontaneous in patients with COPD; traumatic due to acute trauma or iatrogenic; shock may occur if rapidly increasing (tension pneumothorax)

  • Pulmonary hypertension:

cardiac-sounding chest pain on exertion, dyspnoea; symptoms of right-sided heart failure such as lower extremity oedema, abdominal bloating, or ascites; syncope if severe

  • Peptic ulcer disease:

gastric ulcers: epigastric pain or burning with onset 5 to 15 minutes after eating and may last for several hours; duodenal ulcers: epigastric pain is relieved by eating and may return 1 to 4 hours postprandially; pain from any ulcer is relieved by antacid; risk factors: cigarette smoking, NSAIDs, and chronic alcohol consumption

  • Oesophageal spasm:

crushing substernal chest pain, associated dysphagia, pain does not always correlate with swallowing, dysphagia precipitated by very hot or cold foods, glyceryl trinitrate can relieve the pain

  • Acute cholecystitis:

right upper quadrant pain, radiation to the interscapular area or right shoulder, associated with nausea and vomiting, fevers, anorexia often accompanies pain, signs of peritoneal inflammation such as abdominal pain with jarring

  • Pancreatitis: 

epigastric or periumbilical abdominal pain that radiates to the back; may be severe; associated nausea and vomiting; history of alcohol consumption or gallstones

  • Herpes zoster:

unilateral, burning pain in typical dermatome distribution that may occur before appearance of rash and may persist for >1 month

  • Gastritis:

dyspepsia/epigastric discomfort; nausea, vomiting, loss of appetite; history of NSAID use or alcohol misuse; history of Helicobacter pylori infection; history of previous gastric or abdominal surgery.

Ask for risk factors of cardiovascular disease including smoking, hypertension, hypercholesterolaemia, diabetes, family history of premature vascular disease in suspected cardiac causes of chest pain.

Past medical/surgical history should focus on previous hospital admissions, operations, medication use, immunisations, allergies, and current comorbidities.

Family and social history further probes risk factors for possible genetic or familial aetiologies as well as lifestyle contributions to the disease process.

Drug and allergy history explores current drug use and previous allergies to any known drug.

Review of other systems not covered in the body of the history.

Physical examination

  • Acute coronary syndrome: 

examination may be normal; jugular venous distention, S4 gallop, holosystolic murmur (mitral regurgitation), bibasilar rales; hypotensive, tachycardic, bradycardic, or hypoxic depending on severity of ischaemia

  • Stable angina:

no specific findings for CAD, may have abnormal pulses if peripheral vascular disease present

  • Pulmonary embolism:

tachycardia, loud P2, right-sided S4 gallop, jugular venous distention, fever, right ventricular lift; massive PE may cause hypotension

  • Pneumonia:

decreased breath sounds, rales, wheezing, bronchial breath sounds, dullness to percussion, and increased tactile fremitus observed with severe consolidation

  • Viral pleuritis:

pleural friction rub with or without low-grade fever; sometimes reproducible tenderness to palpation of chest when perichondritis or pleurodynia accompanies pleuritis

  • Gastro Oesophageal Reflux Disease:

no specific physical findings

  • Costochondritis:

reproducible pain, especially at the costochondral junctions

  • Anxiety or panic disorder:

hyperventilation, examination otherwise normal

  • Pericarditis:

tachycardia and friction rub; jugular venous distention and pulsus paradoxus indicate effusion causing tamponade

  • Cardiac tamponade: 

hypotension, distended neck veins, muffled heart sounds; pulsus paradoxus (a drop of ≥10 mmHg in arterial BP on inspiration)

  • Aortic dissection:

unequal pulses or BPs in both arms; new diastolic murmur due to aortic regurgitation; muffled heart sounds if the dissection is complicated by cardiac tamponade; new focal neurological findings due to involvement of the carotid or vertebral arteries

  • Aortic stenosis:

ejection systolic murmur that radiates to the neck; obliteration of S2 indicates severe stenosis; delayed upstroke on palpation of carotid pulse

  • Mitral valve prolapse:

mid-systolic click and late systolic murmur at the apex

  • Pneumothorax:

absent breath sounds, increased resonance to percussion; jugular venous distention, trachea deviation, and hypotension if tension pneumothorax (due to compromise of the great vessels)

  • Pulmonary hypertension:

accentuated pulmonic component (P2) to the second heart sound; palpable P2; right ventricular heave; lower extremity oedema; jugular venous distention

  • Peptic ulcer disease:

epigastric tenderness; if significant bleeding is present there may be tachycardia, hypotension, and conjunctival pallor

  • Oesophageal spasm:

no specific findings

  • Acute cholecystitis:

right upper quadrant tenderness (Murphy’s sign), abdominal rigidity and guarding if perforation of the gallbladder, rarely have jaundice early in the course of cholecystitis

  • Pancreatitis: 

tachycardic, hypotensive, febrile, acute distress; ecchymosis in the periumbilical region (Cullen’s sign) and the flank (Grey-Turner sign)

  • Herpes zoster:

vesicular rash on erythematous base, in unilateral distribution of a dermatome

  • Gastritis:

epigastric gastric discomfort may be present; may have signs associated with vitamin B12 deficiency and pernicious anaemia (e.g., abnormal neurological examination, presence of cognitive impairment, angular cheilitis, atrophic glossitis

Appropriate lab investigations may then be requested to strengthen clinical impression made at the end of history and examination.