History-taking
CPSA · Focused history · Cardiovascular
Chest pain
The priority is to separate the immediately life-threatening causes (ACS, PE, aortic dissection) from benign ones. Characterise the pain (SOCRATES) and screen the killers.
Focused questions
Characterise (SOCRATES)
- Site, Onset (sudden/exertional), Character (crushing/tearing/pleuritic), Radiation (jaw/arm/back), Associated (sweating, nausea, breathlessness), Timing, Exacerbating/relieving (exertion, GTN, movement, food), Severity
Screen the killers
- ACS: central/crushing, radiates to jaw/arm, sweating, nausea, worse on exertion
- PE: pleuritic, breathless, haemoptysis, calf pain, recent immobility/surgery
- Dissection: sudden tearing pain radiating to the back, unequal
- Also GORD, musculoskeletal, pericarditis, pneumonia
Risk factors
- Cardiac: smoking, diabetes, hypertension, cholesterol, family history
- VTE: recent surgery/immobility, malignancy, COCP, prior DVT/PE
Differentials to screen
Acute coronary syndromeCentral crushing pain, radiates to jaw/arm, sweating, worse on exertion
Pulmonary embolismPleuritic, breathless, tachycardic, VTE risk factors
Aortic dissectionSudden tearing pain to the back, unequal BP/pulses
PericarditisSharp, worse lying flat, better sitting forward, recent viral illness
GORD / musculoskeletalRelated to food/posture or reproducible on palpation
Red flags — exclude these
- Haemodynamic instability
- Tearing pain to the back (dissection)
- Pleuritic pain with breathlessness/haemoptysis (PE)
- Exertional pain with autonomic features (ACS)
OSCE tips
- Actively exclude the three killers (ACS, PE, dissection) in every chest-pain history.
- Ask about VTE risk factors — easily forgotten and exam-relevant.
- Offer an ECG and troponin as your immediate next steps.