What questions should be asked when evaluating a patient with chest pain during an examination?

Essential Questions to Ask When Evaluating Chest Pain

When evaluating a patient with chest pain, a systematic approach focusing on specific characteristics of the pain and associated symptoms should be employed to identify potentially life-threatening conditions and guide appropriate management. 1

Chest Pain Characteristics to Assess

Nature of Pain

• Is the pain retrosternal discomfort (heaviness, tightness, pressure, squeezing)? Suggests cardiac ischemia
• Is the pain sharp and increases with inspiration or lying supine? Suggests pericarditis
• Is the pain described as "ripping" or "tearing"? Suggests aortic dissection
• Is the pain localized to a very specific area or reproducible with palpation? Suggests non-cardiac origin 1

Onset and Duration

• Did the pain gradually build over minutes? Suggests angina
• Was the onset sudden with "ripping" quality? Suggests aortic dissection
• Is the pain fleeting (seconds duration)? Less likely to be cardiac
• Has the pain been persistent or worsening? Suggests need for urgent evaluation 1

Location and Radiation

• Is the pain retrosternal with radiation to left arm, shoulders, neck, or jaw? Suggests cardiac origin
• Does the pain radiate to both arms? Highly specific for ACS (specificity 96%) 2
• Does the pain radiate to the back? Consider aortic dissection
• Does the pain radiate below the umbilicus or hip? Less likely cardiac 1

Precipitating Factors

• Is the pain triggered by physical exertion or emotional stress? Suggests angina
• Does the pain occur at rest or with minimal exertion? Suggests ACS
• Is the pain positional or affected by movement? Suggests musculoskeletal origin
• Is the pain pleuritic (worsened by breathing)? Suggests pulmonary or pleural etiology 1

Relieving Factors

• Note: Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia 1, 3
• Does rest relieve the pain? Suggests stable angina
• Does the pain worsen in supine position? Suggests pericarditis 1

Associated Symptoms

• Dyspnea, diaphoresis, nausea/vomiting? Suggests cardiac origin
• Lightheadedness, presyncope, or syncope? Suggests significant cardiac issue
• Fever? Suggests infectious etiology (pericarditis, pneumonia)
• Palpitations? Consider arrhythmia as cause or consequence 1

Physical Examination Focus Points

Vital Signs

• Tachycardia and hypotension? Suggests cardiogenic shock
• Tachycardia with dyspnea? Present in >90% of pulmonary embolism cases
• Fever? Suggests infectious etiology 1

Cardiovascular Examination

• Pulse differential between extremities? Suggests aortic dissection
• Presence of S3, murmur, or crackles? Suggests heart failure or valvular disease
• Pericardial friction rub? Suggests pericarditis 1

Respiratory Examination

• Unilateral decreased or absent breath sounds? Consider pneumothorax
• Regional dullness to percussion or egophony? Suggests pneumonia
• Subcutaneous emphysema? Consider esophageal rupture 1

Chest Wall Examination

• Tenderness of costochondral joints? Suggests costochondritis
• Reproducible pain with palpation? Suggests musculoskeletal origin 1

Special Considerations for Older Patients

For patients ≥75 years of age, ask about:

• Shortness of breath
• Syncope or near-syncope
• Acute confusion/delirium
• Recent unexplained falls 1

Diagnostic Testing Questions

ECG Considerations

• Has an ECG been performed within 10 minutes of arrival? Required for all chest pain patients
• Are there any ST-segment elevations or depressions? ST-depression has high specificity (95%) for ACS
• Are there any new T-wave inversions or other ischemic changes?
• For non-diagnostic initial ECG in suspected ACS, serial ECGs should be performed 1

Cardiac Biomarkers

• Has cardiac troponin been measured as soon as possible after presentation?
• Are serial troponin measurements planned if initial is negative but suspicion remains high? 1

Risk Stratification

Consider using validated risk scores:

• HEART score (History, ECG, Age, Risk factors, Troponin)
• TIMI score (Thrombolysis in Myocardial Infarction)

These scores incorporate history elements with other clinical data and significantly improve diagnostic accuracy compared to history alone 2

Common Pitfalls to Avoid

1. Assuming relief with nitroglycerin confirms cardiac origin - this is not a reliable diagnostic criterion 1, 3

2. Dismissing chest pain in younger patients - ACS can occur at any age

3. Over-relying on "typical" vs "atypical" categorization - instead focus on specific characteristics that increase or decrease likelihood of ACS 1

4. Delaying ECG beyond 10 minutes - this can significantly impact outcomes for STEMI patients 1

5. Discharging patients with concerning symptoms without appropriate testing - history alone cannot safely rule out ACS 4, 2

6. Failing to consider non-cardiac life-threatening causes - such as aortic dissection, pulmonary embolism, pneumothorax, or esophageal rupture 5

By systematically addressing these key questions during evaluation, clinicians can better identify patients with potentially life-threatening causes of chest pain and ensure appropriate management to reduce morbidity and mortality.