Chest Pain History Taking OSCE Station Guide and Mark Scheme

Chest pain history taking OSCE stations are one of the most common scenarios in a clinical exam as chest pain is a common and potentially very serious presentation in the emergency department or general practice. The presentation is often acute chest pain in the OSCE scenario. It is really important to do a full SOCRATES on the pain but do not forget to ask about risk factors for cardiovascular disease as well as PE if either is indicated (in any chest pain OSCE you should be asking about smoking, family history etc anyway). Below gives a chest pain OSCE checklist and guide which will cover all the main points to the history. Make sure you learn this guide well as it will set you up in good stead for both exams and real life!

Candidate's Instructions

You are a junior doctor working in the emergency department. Mrs Chamberlain has presented with chest pain. Take a relevant history from Mrs Chamberlain and provide a differential diagnosis, including your most likely diagnosis.

Mark scheme

Introduction:

Give your full name and role
Confirm name and age of patient
Explain the purpose of the interview and obtain consent to talk to the patient
Ask if patient is currently in pain (offer pain relief if so)

Characteristics of pain:

Open questioning to start - e.g. What brings you into today? Can you tell me about the pain? How would you describe it?
Establish site of pain - often useful to ask the patient to point to where the pain is (retrosternal pain can indicate ischaemia or acid reflex, superficial pain can indicate a musculoskeletal problem)
Establish onset of pain (ischaemia tends to be slow and insidious whereas a pneumothorax or pulmonary embolism may be sudden onset)
Establish character of pain (ischaemia - crushing, retrosternal, 'as if someone is sitting on my chest', 'like a band around my chest'; aortic dissection - sharp, tearing persisting; pneumothorax - sudden, sharp, like a knife, 'pleuritic'; reflux - burning, 'heartburn')
Establish radiation of pain (ischaemia - radiates to left arm and jaw; aortic dissection - radiating to the back between shoulder blades; reflux - radiates from epigastrium to throat)
Establish associated symptoms - nausea, vomiting, sweating, palpitations, dyspnoea (breathlessness), leg swelling/tenderness, haemoptysis (coughing up blood), symptoms of infection (fever etc)
Establish duration and progression of symptoms
Establish exacerbating factors (worsened/caused by inspiration - pneumothorax, pulmonary embolism, pneumonia; worsened/caused by lying down and inspiration/coughing - pericarditis; local area of tenderness - musculoskeletal pain; worse/caused by exercise, stress, eating, emotion - angina)
Establish relieving factors (relived by sitting up - pericarditis; relieved by rest/GTN spray - angina)
Establish severity of pain - and rate it from a scale of 1-10

Establish risk factors for coronary artery disease:

Smoking
Diabetes
Hypertension
Hypercholesterolaemia
Family history,
History of IHD/stroke

Establish Risk Factors For pulmonary Embolus:

History of pulmonary embolus
Symptoms suggestive of deep vein thrombosis (DVT)
Malignancy
Family history
Recent fracture or surgery
Immobility

Past medical/surgical history:

Medication history/allergies
Social history - occupation, stress at work, employment (stress can precipitate angina, acid reflux and anxiety, while physically demanding jobs can cause musculoskeletal pain)
Elicit patient's ideas, concerns and expectations

Conclusion:

Summarise history back to patient
Thank patient
Offer appropriate differential diagnosis

Investigations

Sometimes you are asked in the exam which investigations you would ask for. As always, split your investigations logically into the following (it makes it easier to remember!)