How to Medicine Series
How to evaluate chest pain
Dr R.J. (BSc, MBBS (QLD))
Specialities: general and acute care medicine, cardiology, respiratory.
Target audience: doctors, medical students, nursing, and any health professional.
Introduction:
• Chest pain is a very common presentation and a prelude to the most common cause of death in
many countries in the world – cardiovascular disease. Its evaluation is an essential skill for all
doctors and helpful for the wider community of healthcare professionals.
• This document offers a framework to evaluating someone with chest pain, especially with severe
symptoms requiring hospital level care.
CASE VIGNETTE:
A 46yo gentleman comes to the emergency department complaining of severe chest pain with
shortness of breath. He looks unwell and his oxygen saturation levels are low.
How would you manage this problem?
1: Differentials
• It is helpful to make a quick mental note of the possible differential causes in your head (table 1)
before even seeing the patient, as it helps guide the rest of your management. The approach to
any problem should have a directed approach with the active exclusion of life-threatening
differentials during the history-taking.
• It often is immediately noticeable when a patient presents with life-threatening diagnoses on the
left side of the table, as their symptoms are usually severe, they are visibly uncomfortable, and
have abnormalities with their vital signs (eg. Low blood pressure, rapid heart rate or tachypnea).
Table 1 – Differential causes of chest pain. Exclude life-threatening causes first, particularly acute
coronary syndrome and pulmonary embolism, as these are more common. Be mindful that it is often
difficult to diagnose some of the causes on the right on initial presentation.
Diagnose or make unlikely as a matter of priority Other causes
Acute coronary syndrome (very common!) Other cardiac causes but without cardiac ischaemia –
stable angina, aortic stenosis, pericarditis / myocarditis.
Heart failure can give a vague discomfort.
Pulmonary embolism (does not always present Pneumonia
classically)
Acute aortic dissection (will present with severe Gastrointestinal causes – gastroesophageal reflux
symptoms usually or hypotension). (common), hiatal hernia
Tension pneumothorax Pancreatitis (can be referred to chest)
Pericardial tamponade Musculoskeletal causes – costochondritis (common),
trauma or fracture.
Oesophageal rupture and mediastinitis (uncommon, Psychiatric causes – anxiety / panic attacks (diagnosis of
will present very unwell). exclusion).
Uncommon causes – connective tissue disease (SLE,
Kawasaki’s disease, Takayasu’s arteritis), Herpes zoster.
1
, How to Medicine Series
2: History
• The history offers critical information and cannot be underestimated!
• The history of the presenting complaint: it is essential to gather an understanding of WHEN the
chest pain started and how it continued to develop afterwards. Ask the patient:
o When did your pain start?
o Did it come on suddenly or was it gradually? (The classic pain of acute coronary
syndrome is gradual).
o What did your pain feel like? Was it sharp, dull or aching?
o Did your pain radiate to your shoulders, arms, neck, jaw or back?
o How severe was the pain at its worst?
o Was it persistent or did it come and go?
o What were you doing at the time? Were you emotionally or physically stressed?
o Has this happened before?
o Does it improve with medication or rest?
• Associated features: some other symptoms on the history will make other causes more or less
likely. Ask the patient:
o Are you short of breath?
o Did you have any palpitations?
o Were you dizzy, or did you lose consciousness, at any time?
o Did you have any nausea or vomiting?
o Do you have any fevers, shakes or chills?
o Are there any other infectious symptoms, like a rash or muscle pain?
• Background: ask briefly about the patient’s medical history.
o Cardiovascular disease: have you have a heart attack in the past? Do you have a family
history of early cardiac death?
o Do you have a history of diabetes, hypertension or high cholesterol levels?
o Do you have any other medical problems, specifically liver, kidney or lung disease?
o Pulmonary embolism risk factors: have you ever had a blood clot in your legs or lungs in
the past? Do you have any blood clotting disorders? Have you recently had a long-haul
flight? Have you recently been hospitalised or had recent surgery? Have you had cancer
in the past? Have you been coughing up any blood? Are you on any hormonal therapy or
the contraceptive pill (for females).
• Medications: this will tie in with the background and will be important in management
afterwards if a life-threatening cause is diagnosed. Ask the patient what medications they are on.
• Allergies: ask the patient if they have any allergies, specifically aspirin and other antiplatelet
agents, and any antibiotic therapy if pneumonia is diagnosed.
• Social history: a complete social history is not as important in the evaluation of chest pain but it
is important nonetheless to understand the context of the patient’s presentation. Ask briefly
about their smoking and alcohol history, any intravenous drug use, occupation, stressors in life
and whether they are independent at home.
3: Examination
• The examination for chest pain should follow a systematic approach, but there is no need to
spend a significant amount of time here, as most of the diagnosis is made in the history and the
investigations.
• You are trying to find features that would suggest a severe form of disease – such as
complications of myocardial infarction (eg. Decompensated heart failure, blown mitral valve) or
features of sepsis. Unless you feel very gifting, there is no need to perform a detailed examination
such as appreciating a displaced apex beat or a palpable P2.
• See ”How to perform the cardiovascular exam” for a more detailed version and explanation of
this examination.
2
How to evaluate chest pain
Dr R.J. (BSc, MBBS (QLD))
Specialities: general and acute care medicine, cardiology, respiratory.
Target audience: doctors, medical students, nursing, and any health professional.
Introduction:
• Chest pain is a very common presentation and a prelude to the most common cause of death in
many countries in the world – cardiovascular disease. Its evaluation is an essential skill for all
doctors and helpful for the wider community of healthcare professionals.
• This document offers a framework to evaluating someone with chest pain, especially with severe
symptoms requiring hospital level care.
CASE VIGNETTE:
A 46yo gentleman comes to the emergency department complaining of severe chest pain with
shortness of breath. He looks unwell and his oxygen saturation levels are low.
How would you manage this problem?
1: Differentials
• It is helpful to make a quick mental note of the possible differential causes in your head (table 1)
before even seeing the patient, as it helps guide the rest of your management. The approach to
any problem should have a directed approach with the active exclusion of life-threatening
differentials during the history-taking.
• It often is immediately noticeable when a patient presents with life-threatening diagnoses on the
left side of the table, as their symptoms are usually severe, they are visibly uncomfortable, and
have abnormalities with their vital signs (eg. Low blood pressure, rapid heart rate or tachypnea).
Table 1 – Differential causes of chest pain. Exclude life-threatening causes first, particularly acute
coronary syndrome and pulmonary embolism, as these are more common. Be mindful that it is often
difficult to diagnose some of the causes on the right on initial presentation.
Diagnose or make unlikely as a matter of priority Other causes
Acute coronary syndrome (very common!) Other cardiac causes but without cardiac ischaemia –
stable angina, aortic stenosis, pericarditis / myocarditis.
Heart failure can give a vague discomfort.
Pulmonary embolism (does not always present Pneumonia
classically)
Acute aortic dissection (will present with severe Gastrointestinal causes – gastroesophageal reflux
symptoms usually or hypotension). (common), hiatal hernia
Tension pneumothorax Pancreatitis (can be referred to chest)
Pericardial tamponade Musculoskeletal causes – costochondritis (common),
trauma or fracture.
Oesophageal rupture and mediastinitis (uncommon, Psychiatric causes – anxiety / panic attacks (diagnosis of
will present very unwell). exclusion).
Uncommon causes – connective tissue disease (SLE,
Kawasaki’s disease, Takayasu’s arteritis), Herpes zoster.
1
, How to Medicine Series
2: History
• The history offers critical information and cannot be underestimated!
• The history of the presenting complaint: it is essential to gather an understanding of WHEN the
chest pain started and how it continued to develop afterwards. Ask the patient:
o When did your pain start?
o Did it come on suddenly or was it gradually? (The classic pain of acute coronary
syndrome is gradual).
o What did your pain feel like? Was it sharp, dull or aching?
o Did your pain radiate to your shoulders, arms, neck, jaw or back?
o How severe was the pain at its worst?
o Was it persistent or did it come and go?
o What were you doing at the time? Were you emotionally or physically stressed?
o Has this happened before?
o Does it improve with medication or rest?
• Associated features: some other symptoms on the history will make other causes more or less
likely. Ask the patient:
o Are you short of breath?
o Did you have any palpitations?
o Were you dizzy, or did you lose consciousness, at any time?
o Did you have any nausea or vomiting?
o Do you have any fevers, shakes or chills?
o Are there any other infectious symptoms, like a rash or muscle pain?
• Background: ask briefly about the patient’s medical history.
o Cardiovascular disease: have you have a heart attack in the past? Do you have a family
history of early cardiac death?
o Do you have a history of diabetes, hypertension or high cholesterol levels?
o Do you have any other medical problems, specifically liver, kidney or lung disease?
o Pulmonary embolism risk factors: have you ever had a blood clot in your legs or lungs in
the past? Do you have any blood clotting disorders? Have you recently had a long-haul
flight? Have you recently been hospitalised or had recent surgery? Have you had cancer
in the past? Have you been coughing up any blood? Are you on any hormonal therapy or
the contraceptive pill (for females).
• Medications: this will tie in with the background and will be important in management
afterwards if a life-threatening cause is diagnosed. Ask the patient what medications they are on.
• Allergies: ask the patient if they have any allergies, specifically aspirin and other antiplatelet
agents, and any antibiotic therapy if pneumonia is diagnosed.
• Social history: a complete social history is not as important in the evaluation of chest pain but it
is important nonetheless to understand the context of the patient’s presentation. Ask briefly
about their smoking and alcohol history, any intravenous drug use, occupation, stressors in life
and whether they are independent at home.
3: Examination
• The examination for chest pain should follow a systematic approach, but there is no need to
spend a significant amount of time here, as most of the diagnosis is made in the history and the
investigations.
• You are trying to find features that would suggest a severe form of disease – such as
complications of myocardial infarction (eg. Decompensated heart failure, blown mitral valve) or
features of sepsis. Unless you feel very gifting, there is no need to perform a detailed examination
such as appreciating a displaced apex beat or a palpable P2.
• See ”How to perform the cardiovascular exam” for a more detailed version and explanation of
this examination.
2
