Taking a comprehensive chest pain history is an important skill that is often assessed in OSCEs. This guide provides a structured framework for taking a chest pain history in an OSCE setting. Show
Download the chest pain history taking PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our cardiovascular history taking guide. Opening the consultationWash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth. Explain that you’d like to take a history from the patient. Gain consent to proceed with history taking. General communication skillsIt is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient). Some general communication skills which apply to all patient consultations include:
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. Presenting complaintUse open questioning to explore the patient’s presenting complaint:
Provide the patient with enough time to answer and avoid interrupting them. Facilitate the patient to expand on their presenting complaint if required:
Open vs closed questionsHistory taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. History of presenting complaintGather further details about the patient’s chest pain using the SOCRATES acronym. SOCRATESThe SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms. SiteAsk about the location of the pain:
OnsetClarify how and when the pain developed:
CharacterAsk about the specific characteristics of the pain:
RadiationAsk if the pain moves anywhere else:
Associated symptomsAsk if there are other symptoms which are associated with the pain:
Time courseClarify how the pain has changed over time:
This question can be useful to determine if the chest pain has become progressively worse over time. An example might be a patient describing chest pain that was initially only present during exertion which is now also present at rest (e.g. unstable angina). Exacerbating or relieving factorsAsk if anything makes the pain worse or better:
SeverityAssess the severity of the pain by asking the patient to grade it on a scale of 0-10:
This allows you to assess the patient’s response to treatments (e.g. pain was initially 8/10 and improved to 3/10 with GTN spray). Typical presentations of chest painAcute coronary syndrome:
Stable angina:
Pericarditis:
Thoracic aortic dissection:
Pneumonia:
Spontaneous pneumothorax:
Pulmonary embolism:
Gastro-oesophageal reflux:
Oesophageal spasm:
Cardiovascular risk factorsWhen taking a cardiovascular history it’s essential that you identify risk factors for cardiovascular disease as you work through the patient’s history (e.g. past medical history, family history, social history). Important cardiovascular risk factors include:
Ideas, concerns and expectationsA key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic. It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below. IdeasExplore the patient’s ideas about the current issue:
ConcernsExplore the patient’s current concerns:
ExpectationsAsk what the patient hopes to gain from the consultation:
SummarisingSummarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. SignpostingSignposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next. Signposting examplesExplain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.” What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.” Systemic enquiryA systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint. Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience. Some examples of symptoms you could screen for in each system include:
Past medical historyAsk if the patient has any medical conditions:
Ask if the patient has previously undergone any surgery (e.g. coronary artery bypass grafts, coronary artery stents, heart valve replacements):
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions. Examples of relevant medical conditionsCardiovascular disease:
Respiratory disease:
Gastrointestinal disease:
AllergiesAsk if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis). Drug historyAsk if the patient is currently taking any prescribed medications or over-the-counter remedies:
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route. Ask the patient if they’re currently experiencing any side effects from their medication:
Medication examplesMedications commonly prescribed to patients with medical conditions relevant to chest pain:
Family historyAsk the patient if there is any family history of diseases which may be associated with chest pain (e.g. cardiovascular disease, thromboembolic disease):
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors):
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:
Social historyExplore the patient’s social history to both understand their social context and identify potential risk factors for medical conditions which could present with chest pain. General social contextExplore the patient’s general social context including:
SmokingSmoking increases the risk of cardiovascular disease (e.g. myocardial infarction, angina), venous thromboembolism (e.g. pulmonary embolism) and pneumonia. Record the patient’s smoking history, including the type and amount of tobacco used. Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk profile:
See our smoking cessation guide for more details. AlcoholRecord the frequency, type and volume of alcohol consumed on a weekly basis. See our alcohol history taking guide for more information. Recreational drug useAsk the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Recreational drugs may be the underlying cause of a patient’s presentation with chest pain symptoms:
GamblingAsk the patient if they gamble and if they feel this is a problem. Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1 Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI). DietAsk if the patient what their diet looks like on an average day. Take note of unhealthy foods which are known to contribute to cardiovascular disease (e.g. high salt intake, high saturated fat intake). ExerciseAsk if the patient regularly exercises and if so clarify the frequency and activity type of exercise. OccupationAsk about the patient’s current occupation:
DrivingIf the patient drives and has presented with chest pain it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues. Closing the consultationSummarise the key points back to the patient. Ask the patient if they have any questions or concerns that have not been addressed. Thank the patient for their time. Dispose of PPE appropriately and wash your hands. Which questions should a nurse ask a patient who complains of chest pain?Common Errors in Chest Pain Diagnosis.. Do you have a pacemaker?. When did the symptoms start? (onset). How long have your symptoms lasted? (duration). Did you have syncope (fainting), dizziness or lightheadedness?. What do you do if a patient complains of chest pain?If your chest pain is new, changing or otherwise unexplained, seek help from a health care provider. If you think you're having a heart attack, call 911 or your local emergency number. Don't try to diagnose the chest pain yourself or ignore it. Your treatment will depend on the specific cause of the pain.
What should a nurse do when a patient has chest pain?Nursing Management. Manage chest pain.. Bed rest.. Provide oxygen.. Administer aspirin and nitroglycerin.. Place patient with head of the bed elevated at 45 degrees.. Make patient comfortable.. Hook up to monitor.. Check vitals.. Where does a nurse palpate to assess the posterior tibial pulse?The posterior tibial pulse can be felt behind and below the medial malleolus. Gently flex the knee and feel for the popliteal pulse by deep palpation in midline in popliteal fossa.
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