01.11 Chest pain
Clerking for chest pain
PC: Chest pain
HPC:
SOCRATES
Associated with
Cardiac: Palpitations, dyspnoea, clamminess/nausea, LOC
Respiratory: Dyspnoea, cough/sputum/haemoptysis, wheeze
Other: Fever
PMH:
DHx:
Allergies:
FHx:
Cardiac conditions – MI / sudden death
SHx:
Smoking –
Alcohol –
Illicit drug use –
Lives with
iADL
O/E:
Obs: NEWS
Ix:
Bloods: ** trops, D-dimer,
VBG:
ECG:
CXR:
Echo:
Other imaging:
Imp:
Plan
Other notes
SOCRACTES
Site
Onset – what were they doing when pain started?
Character
Radiation
Associated with
Timing – timeline of pain (when did it reach maximal severity?)
Exacerbated by / alleviated by
Severity – _/10
Character
Crushing – possibly MI
Sharp / pleuritic – ?PE ?pneumonia
Tearing – ?aortic dissection
Can you point to it with one finger? / Reproducible pain – ?MSK
Radiation
Up the left arm / to the jaw – ?MI
Sudden onset radiating to the back – need to r/o aortic dissection
Associated with
Sweating, nausea, clamminess, dyspnoea – ?ACS (STEMI/NSTEMI/unstable angina) vs ?angina
Dyspnoea – ?MI ?pneumonia ?asthma/COPD
LOC – ?aortic stenosis
Cough/sputum – ?pneumonia
Haemoptysis – ?PE
Fever – ?pneumonia ?pericarditis
Exacerbated by
Deep inspiration – ?PE ?pneumonia ?pneumothorax ?MSK (eg costochondritis)
Lying down – ?pericarditis ?GORD (esp after eating)
Movement / reproducible pain on palpation – ?MSK
Exercise / exertion – ?stable angina
Alleviated by
GTN spray – ?ACS ?stable angina ?oesophageal spasm
Leaning forward – ?pericarditis (classically)
Investigations
Bedside – obs, ECG (± repeat ECG)
Bloods – troponin (including repeat trops), D-dimers, FBC/CRP (for pneumonia)
Imaging – CXR, perfusion angiogram / PCI (for ACS), CT angiogram (to r/o aortic dissection), CTPA (for PE), echo (for pericarditis / pericardial effusion)
Differential diagnoses
Cardiac
Acute coronary syndrome: STEMI, NSTEMI, unstable angina
Pericarditis, myocarditis, pericardial effusion
Aortic dissection, thoracic aortic aneurysm
Respiratory
Pneumonia, pleural effusion
Pneumothorax
Pulmonary embolism
MSK
Injury / trauma
Costochondritis
Gastro
GORD, oesophageal spasm
Pancreatitis (if pt is mistaking epigastric pain for chest pain)
