Chest Pain

1. Overview

Chest pain is a common and high-risk OSCE presentation. The main aim is to identify life-threatening causes early while taking a focused, structured history.

Important life-threatening causes

• Acute coronary syndrome: unstable angina, NSTEMI or STEMI.
• Aortic dissection.
• Pulmonary embolism.
• Tension pneumothorax.
• Pneumonia or sepsis.
• Pericardial tamponade.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the chest pain.
• Gain consent.
• Check whether the patient is currently in pain or acutely unwell.

Presenting complaint

• Ask what brought the patient in today.
• Clarify when the pain started.
• Ask whether the pain is still present.
• Ask whether this is the first episode.
• Ask what the patient was doing when the pain started.

Pain history: SOCRATES

• Site: central, left-sided, right-sided, retrosternal or epigastric.
• Onset: sudden, gradual, exertional, at rest, after meals or after trauma.
• Character: crushing, tight, heavy, sharp, stabbing, tearing or burning.
• Radiation: left arm, jaw, neck, back, shoulder or epigastrium.
• Associated symptoms: shortness of breath, sweating, nausea, vomiting, palpitations, syncope, cough, fever or haemoptysis.
• Timing: constant, intermittent, duration and frequency.
• Exacerbating factors: exertion, breathing, coughing, lying flat, movement, palpation or eating.
• Relieving factors: rest, GTN, antacids, sitting forward, analgesia or change in position.
• Severity: ask for a score from 0 to 10.

Associated symptoms

• Sweating, nausea or vomiting may suggest myocardial infarction.
• Breathlessness may suggest ACS, heart failure, PE, pneumonia or pneumothorax.
• Palpitations may suggest arrhythmia.
• Syncope may suggest arrhythmia, massive PE, aortic stenosis or haemodynamic compromise.
• Haemoptysis may suggest PE, pneumonia, TB or malignancy.
• Fever and productive cough may suggest pneumonia.
• Tearing chest pain radiating to the back may suggest aortic dissection.
• Pain worse lying flat and relieved by sitting forward may suggest pericarditis.
• Burning retrosternal pain after meals may suggest reflux.

Cardiovascular risk factors

• Hypertension.
• Diabetes mellitus.
• Hyperlipidaemia.
• Smoking.
• Obesity.
• Previous angina, myocardial infarction, PCI or CABG.
• Chronic kidney disease.
• Family history of premature ischaemic heart disease.
• Cocaine or stimulant use.

PE risk factors

• Recent surgery or hospital admission.
• Recent long-distance travel or immobilisation.
• Previous DVT or PE.
• Active cancer.
• Pregnancy or postpartum state.
• Oestrogen-containing contraception or hormone therapy.
• Unilateral calf pain or swelling.

Aortic dissection risk factors

• Severe hypertension.
• Known aortic aneurysm.
• Connective tissue disease such as Marfan syndrome.
• Bicuspid aortic valve.
• Recent cardiac or vascular procedure.
• Pregnancy, especially late pregnancy or postpartum.
• Cocaine or stimulant use.

Past medical history

• Ischaemic heart disease, angina or previous MI.
• Heart failure, valvular disease or arrhythmia.
• Hypertension, diabetes or hyperlipidaemia.
• Asthma, COPD, pneumonia or previous pneumothorax.
• GORD or peptic ulcer disease.
• Previous DVT or PE.
• Known malignancy.
• Recent trauma.

Drug history and allergies

• Current medications.
• Antiplatelets such as aspirin, clopidogrel, ticagrelor or prasugrel.
• Anticoagulants such as warfarin, apixaban, rivaroxaban, dabigatran or heparin.
• GTN spray, beta-blockers, calcium channel blockers or nitrates.
• Statins, antihypertensives and diabetic medications.
• Ask about sildenafil or other erectile dysfunction drugs if nitrates may be used.
• Ask about allergies and the reaction.

Family history

• Family history of premature ischaemic heart disease.
• Sudden cardiac death.
• Inherited arrhythmia or cardiomyopathy.
• Thrombophilia or recurrent venous thromboembolism.
• Aortic disease or connective tissue disorders.

Social history

• Smoking history in pack-years.
• Alcohol intake.
• Recreational drug use, especially cocaine or amphetamines.
• Occupation and functional status.
• Exercise tolerance.
• Diet and physical activity.
• Living situation and support at home.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the pain.
• Ask what they are most worried about, such as a heart attack.
• Ask what they were hoping would happen today.
• Acknowledge anxiety and explain that chest pain is taken seriously.

Red flags

• Severe central crushing chest pain.
• Pain radiating to arm, jaw, neck or back.
• Sweating, nausea or vomiting.
• Syncope or collapse.
• Severe breathlessness.
• Haemoptysis.
• Sudden tearing pain radiating to the back.
• Hypotension or shock.
• Neurological symptoms with chest pain.
• Known cardiovascular disease with new or worsening pain.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine them and arrange urgent investigations if clinically indicated.

3. Physical Examination

The examination should be guided by the patient's stability. If the patient appears acutely unwell, start with an ABCDE assessment before performing a focused cardiovascular, respiratory and targeted examination.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient has any pain at present.
• Position the patient at 45 degrees.
• Ensure adequate exposure of the chest while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment: is the patient unstable?

• Look from the end of the bed: is the patient comfortable, distressed, breathless, pale, sweaty or cyanosed?
• Assess whether the patient is speaking in full sentences.
• Look for oxygen therapy, cardiac monitor, IV lines, GTN spray, nebulisers or resuscitation equipment.
• If the patient looks acutely unwell, state that you would perform an ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether the airway is patent.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing, chest expansion and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level, pupils if indicated and capillary blood glucose.
• Exposure: check temperature, inspect for rashes, trauma, surgical scars and signs of DVT while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Pain score.
• Blood pressure in both arms if aortic dissection is suspected.

Hands

• Inspect for peripheral cyanosis.
• Look for clubbing, which may suggest chronic respiratory disease, infective endocarditis or malignancy.
• Look for splinter haemorrhages, which may suggest infective endocarditis.
• Look for nicotine staining as a cardiovascular and respiratory risk factor.
• Check for palmar pallor suggesting anaemia.
• Feel temperature of the hands.
• Assess capillary refill time.

Pulse

• Assess radial pulse rate.
• Assess rhythm: regular or irregular.
• Assess volume.
• Check for radio-radial delay if vascular disease is suspected.
• Check radio-femoral delay if coarctation or major vascular disease is relevant.
• Assess for an irregularly irregular pulse suggesting atrial fibrillation.

Blood pressure

• Measure blood pressure accurately.
• Measure blood pressure in both arms if aortic dissection is suspected.
• Look for hypotension, which may suggest shock, massive PE, inferior MI, tamponade or severe sepsis.
• Look for hypertension, which is a risk factor for ACS and aortic dissection.

Face and eyes

• Look for conjunctival pallor suggesting anaemia.
• Look for central cyanosis on the tongue.
• Look for xanthelasma as a sign of hyperlipidaemia.
• Look for corneal arcus, especially if premature.
• Assess for facial sweating or distress.

Neck

• Assess jugular venous pressure at 45 degrees.
• Raised JVP may suggest heart failure, tamponade, tension pneumothorax or massive PE.
• Assess carotid pulse if appropriate.
• Auscultate for carotid bruits if vascular disease is suspected.
• Do not palpate both carotids at the same time.

Precordial inspection

• Inspect the chest for scars, including previous sternotomy or thoracotomy scars.
• Look for pacemaker or ICD scars.
• Look for chest wall deformity.
• Look for visible pulsations.
• Look for respiratory distress or use of accessory muscles.
• Look for bruising or trauma.

Palpation of the chest

• Palpate the apex beat and describe its location.
• A displaced apex beat may suggest cardiomegaly.
• A heaving apex may suggest pressure overload.
• A tapping apex may suggest mitral stenosis.
• Palpate for a left parasternal heave, which may suggest right ventricular hypertrophy.
• Palpate for thrills over the valve areas.
• Palpate the chest wall for tenderness if musculoskeletal chest pain is suspected.

Auscultation of the heart

• Auscultate the aortic area.
• Auscultate the pulmonary area.
• Auscultate the tricuspid area.
• Auscultate the mitral area.
• Identify first and second heart sounds.
• Listen for added heart sounds such as S3 or S4.
• Listen for murmurs.
• Listen for a pericardial rub, especially if pericarditis is suspected.
• Auscultate with the bell at the apex for low-pitched murmurs if relevant.
• Auscultate with the patient leaning forward in expiration for aortic regurgitation if relevant.

Signs of heart failure

• Raised JVP.
• Displaced apex beat.
• Third heart sound.
• Bibasal lung crackles.
• Peripheral pitting oedema.
• Hepatomegaly or ascites if advanced right-sided heart failure.

Respiratory examination

• Inspect respiratory rate, work of breathing and symmetry of chest movement.
• Assess chest expansion.
• Percuss the chest for dullness or hyperresonance.
• Auscultate for reduced breath sounds.
• Listen for crackles, wheeze or bronchial breathing.
• Reduced breath sounds with hyperresonance may suggest pneumothorax.
• Crackles may suggest pulmonary oedema or pneumonia.
• Bronchial breathing may suggest consolidation.
• Wheeze may suggest asthma or COPD.

Calves and peripheral vascular examination

• Inspect both calves for asymmetry.
• Look for unilateral swelling, erythema or tenderness suggesting DVT.
• Assess peripheral pulses if vascular disease is suspected.
• Check for peripheral oedema.
• Look for signs of chronic venous disease if relevant.

Abdominal examination if indicated

• Examine the abdomen if pain is epigastric, right upper quadrant or related to meals.
• Look for epigastric tenderness suggesting gastritis or peptic ulcer disease.
• Look for right upper quadrant tenderness suggesting biliary disease.
• Assess for hepatomegaly if heart failure or liver disease is suspected.
• Assess for abdominal aortic aneurysm if appropriate.

Specific findings to mention in chest pain OSCE

• ACS may have a normal examination, so do not be falsely reassured.
• Pericarditis may have a pericardial friction rub.
• Heart failure may have raised JVP, S3, basal crackles and peripheral oedema.
• Aortic dissection may have unequal arm blood pressures, pulse deficit or neurological signs.
• PE may have tachycardia, hypoxia, pleuritic pain and signs of DVT.
• Pneumothorax may have reduced expansion, hyperresonance and reduced breath sounds.
• Pneumonia may have fever, crackles, bronchial breathing or dullness to percussion.
• Costochondritis may have localized reproducible chest wall tenderness.

To complete the examination

To complete my examination, I would review the patient's observations, perform a 12-lead ECG urgently, check troponin and relevant blood tests, request a chest X-ray, and arrange further imaging such as CTPA or CT aortogram if pulmonary embolism or aortic dissection is suspected. I would also escalate urgently to a senior doctor or cardiology team if there are features of ACS or another life-threatening cause.

4. Differential Diagnosis

Cardiac causes

• Acute coronary syndrome: central crushing pain, radiation to arm or jaw, sweating, nausea, dyspnoea and cardiovascular risk factors.
• Stable angina: exertional chest tightness relieved by rest or GTN.
• Pericarditis: sharp pleuritic pain worse lying flat and relieved by sitting forward.
• Myocarditis: chest pain with viral prodrome, dyspnoea, arrhythmia or heart failure features.
• Aortic stenosis: exertional chest pain, syncope and dyspnoea with an ejection systolic murmur.

Vascular causes

• Aortic dissection: sudden severe tearing chest or back pain, pulse deficit, neurological symptoms or unequal blood pressure.
• Pulmonary embolism: pleuritic chest pain, dyspnoea, tachycardia, haemoptysis, syncope or VTE risk factors.

Respiratory causes

• Pneumothorax: sudden pleuritic pain and breathlessness, reduced breath sounds and hyperresonance.
• Pneumonia: fever, cough, sputum, pleuritic pain and focal chest signs.
• Pleurisy: sharp pain worse on inspiration, often post-viral or inflammatory.
• Asthma or COPD exacerbation: wheeze, breathlessness and chest tightness.

Gastrointestinal causes

• Gastro-oesophageal reflux disease: burning retrosternal pain, worse after meals or lying flat.
• Oesophageal spasm: severe retrosternal pain that can mimic angina.
• Peptic ulcer disease or gastritis: epigastric pain related to meals or NSAID use.
• Biliary colic: right upper quadrant or epigastric pain radiating to the back or shoulder.

Musculoskeletal and other causes

• Costochondritis: localized chest wall pain reproducible on palpation.
• Muscle strain or rib injury: pain after trauma, coughing or exertion.
• Anxiety or panic attack: chest tightness with hyperventilation, paraesthesia, tremor and fear of dying, after excluding dangerous causes.
• Herpes zoster: burning dermatomal pain, sometimes before rash appears.

5. Investigations

Bedside tests

• 12-lead ECG as soon as possible.
• Repeat ECG if symptoms persist or diagnosis is uncertain.
• Continuous cardiac monitoring if ACS or arrhythmia is suspected.
• Vital signs monitoring.
• Capillary blood glucose if unwell, diabetic or confused.

Blood tests

• High-sensitivity troponin if ACS is suspected.
• Full blood count.
• Urea and electrolytes.
• Liver function tests if abdominal or hepatobiliary cause is suspected.
• CRP if infection or inflammatory cause is suspected.
• Coagulation profile if anticoagulated or before procedures.
• D-dimer only when PE is possible and pre-test probability supports its use.
• Blood gas if hypoxic, shocked or severely unwell.

Imaging and specialist tests

• Chest X-ray.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• CT aortogram if aortic dissection is suspected.
• Echocardiogram if heart failure, valvular disease, pericardial effusion or complications are suspected.
• Coronary angiography if urgent invasive assessment is indicated.

Important points

• A normal ECG does not exclude ACS.
• Troponin may be normal early after symptom onset.
• Raised troponin is not specific for type 1 myocardial infarction.
• Do not diagnose cardiac pain only because pain improves with GTN.

6. Management

Management depends on the likely diagnosis and severity. In an OSCE, start with safety, escalation and immediate stabilization before discussing definitive treatment.

Immediate approach

1. Assess ABCDE if acutely unwell.
2. Call for senior help early if ACS, PE, dissection, pneumothorax, shock or severe hypoxia is suspected.
3. Attach cardiac monitoring.
4. Obtain IV access and take bloods.
5. Perform a 12-lead ECG as soon as possible.
6. Give analgesia and antiemetic treatment if needed.
7. Give oxygen only if hypoxaemic, shocked, in respiratory distress or according to local protocol.

If acute coronary syndrome is suspected

• Give aspirin loading dose if not contraindicated and according to local protocol.
• Use sublingual GTN if not hypotensive and no contraindication.
• Ask about sildenafil or similar medication before giving nitrates.
• Give opioid analgesia if pain is severe and not relieved by nitrates, according to local practice.
• STEMI requires urgent reperfusion, usually primary PCI where available.
• NSTEMI or unstable angina requires risk stratification, antiplatelet therapy, anticoagulation and cardiology review according to local protocol.

If PE is suspected

• Assess haemodynamic stability.
• Use a validated pre-test probability tool according to local protocol.
• Request D-dimer or CTPA depending on probability and pathway.
• Start anticoagulation if PE is likely and bleeding risk is acceptable.
• Massive PE with shock requires urgent senior and specialist input.

If aortic dissection is suspected

• Call senior help urgently.
• Avoid anticoagulation until dissection is excluded unless advised by specialists.
• Request urgent CT aortogram if appropriate.
• Control pain and blood pressure under senior guidance.
• Arrange urgent cardiothoracic or vascular input if confirmed.

If pneumothorax is suspected

• Assess for tension pneumothorax.
• Tension pneumothorax is a clinical diagnosis and requires immediate decompression.
• Stable pneumothorax is managed according to size, symptoms and local protocol.

Long-term management after ACS

• Secondary prevention with antiplatelet therapy, statin and risk factor control.
• Cardiac rehabilitation.
• Smoking cessation.
• Diet, exercise and weight management.
• Diabetes and blood pressure optimization.
• Follow-up with cardiology or primary care.
• Safety-net advice for recurrent chest pain, breathlessness, syncope or collapse.

7. Examiner Questions

1. What are the life-threatening causes of chest pain?
2. What features suggest acute coronary syndrome?
3. What features suggest pulmonary embolism?
4. What features suggest aortic dissection?
5. Why does a normal ECG not exclude ACS?
6. What is the role of troponin?
7. What ECG changes occur in STEMI?
8. What is the difference between unstable angina and NSTEMI?
9. When should oxygen be given?
10. What are contraindications to GTN?
11. Why should you ask about sildenafil?
12. What is the initial management of suspected STEMI?
13. What are the cardiovascular risk factors?
14. What discharge advice would you give after ACS?

Suggested short answers

8. OSCE Pearls

• Check if the patient is currently in pain or unstable at the start.
• Always ask about radiation to arm, jaw, neck and back.
• Always ask about sweating, nausea, breathlessness and syncope.
• Mention cardiovascular risk factors.
• Ask about cocaine or stimulant use, especially in young patients.
• Ask about PE risk factors.
• Ask about tearing pain radiating to the back for dissection.
• Do not rely on pain relief with GTN to diagnose cardiac pain.
• Mention urgent ECG and troponin early.
• A normal ECG does not rule out ACS.
• Escalate early if life-threatening causes are possible.

9. Example Presentation to Examiner

10. References

• NICE CG95: Recent-onset chest pain of suspected cardiac origin.
• NICE NG185: Acute coronary syndromes.
• BNF/NICE treatment summary: Acute coronary syndromes.
• ESC Guidelines for acute coronary syndromes, 2023.
• Local hospital emergency medicine and cardiology protocols.