History of Present Illness for Chest Pain in the Emergency Department
Chief Complaint
"Chest pain"
History of Present Illness
Pain Characteristics (OPQRST Format)
Onset:
- Exact time symptoms began (gradual onset over minutes suggests ACS; sudden "ripping" onset suggests aortic dissection) 1
- Activity at time of onset (exertion, rest, emotional stress, post-meal) 1
- Whether pain awakened patient from sleep 1
Provocation/Palliation:
- Exacerbated by: physical exertion, emotional stress, deep breathing, position changes, palpation of chest wall 1
- Relieved by: rest, nitroglycerin (though response is NOT diagnostic of cardiac ischemia), antacids, position changes 1, 2
- Any self-treatment attempted and response 1
Quality:
- High probability descriptors for ischemia: pressure, dull, squeezing, aching, gripping, burning, heaviness, tightness, retrosternal discomfort 1
- Lower probability descriptors: stabbing, sharp, fleeting (seconds duration), pleuritic, shifting 1
- Avoid using term "atypical" as it can be misinterpreted as benign 1
Region/Radiation:
- Location: retrosternal, left-sided, central (higher probability); right-sided, localized to small area (lower probability) 1
- Radiation patterns: left arm, jaw, neck, shoulders, back (upper back suggests aortic dissection), epigastrium 1, 3
- Pain below umbilicus or hip is unlikely ischemic 1
Severity:
- Numeric pain scale (0-10) 1
- "Worst chest pain of my life" suggests acute aortic syndrome 1, 3
- Functional impact on activities 1
Timing:
- Duration of current episode (fleeting seconds unlikely ischemic; gradual build over minutes suggests ACS) 1
- Pattern: constant vs. intermittent, frequency of episodes, any recent change in pattern (crescendo pattern) 1
- Total time from symptom onset to presentation 1
Associated Symptoms
Cardiac-related symptoms:
- Dyspnea or shortness of breath (particularly important in women and elderly) 1, 3, 4
- Diaphoresis 1, 3, 2
- Nausea/vomiting (more common in women with ACS) 1, 3, 4
- Lightheadedness or dizziness 1, 3
- Syncope or near-syncope (consider in elderly ≥75 years) 1, 4
- Palpitations 3, 2
- Arm pain, jaw pain, or bilateral hand numbness (particularly in women) 3, 4
- Epigastric discomfort or "heartburn" with acute onset 3
- Fatigue (more common in women) 3, 4
Non-cardiac symptoms:
- Cough, hemoptysis (consider PE, pneumonia) 3, 4
- Fever, chills (infectious etiology) 4
- Acute delirium or confusion (particularly in elderly ≥75 years with ACS) 1, 4
- Unexplained fall (consider in elderly ≥75 years) 1
Pertinent Past Medical History
Cardiovascular Risk Factors
- Coronary artery disease: prior MI, prior PCI/stents, prior CABG 1, 3, 2
- Diabetes mellitus (high-risk population even with minimal symptoms) 3, 4
- Hypertension 1, 3, 2
- Hyperlipidemia 1, 3, 2
- Current or former tobacco use (quantify pack-years) 1, 3, 2
- Chronic kidney disease or renal insufficiency (high-risk population) 4
- Peripheral arterial disease 1
- Cerebrovascular disease/prior stroke 1
- Heart failure 1, 2
- Atrial fibrillation 1
Other Relevant Conditions
- Aortic valve disease (bicuspid aortic valve, known aortic dilation—risk for dissection) 1, 3
- Hypertrophic cardiomyopathy 5
- Severe anemia 5
- Dementia (high-risk population for atypical ACS presentation) 4
- Pulmonary disease: COPD, asthma, prior PE 3, 4
- Gastroesophageal reflux disease 2, 6
- Anxiety or panic disorder 2, 6
- Malignancy (PE risk factor) 4
- Hypercoagulable state (PE risk factor) 4
Current Medications
- Antiplatelet agents: aspirin, clopidogrel, ticagrelor, prasugrel 3
- Anticoagulants: warfarin, DOACs, heparin 3, 4
- Cardiac medications: beta-blockers, ACE inhibitors, ARBs, statins, nitrates 3, 5
- Diuretics 5
- Antidepressants (tricyclics can cause dry mouth affecting sublingual nitroglycerin dissolution) 5
- Medications for erectile dysfunction: sildenafil, tadalafil, vardenafil (contraindicated with nitrates) 5
- Guanylate cyclase stimulators: riociguat (contraindicated with nitrates) 5
- Ergotamine or migraine medications (can precipitate angina) 5
- Recent medication changes or non-compliance 1
Allergies
- Drug allergies: particularly aspirin, heparin, contrast dye 3
- Nature of reaction (true allergy vs. intolerance) 3
Past Surgical History
- Prior CABG (dates, number of grafts) 1, 3
- Prior cardiac valve surgery 1
- Recent surgery of any type (PE risk factor) 4
- Vascular surgery 1
Past Procedural History
- Prior PCI/stenting (dates, vessels treated, stent type) 1, 3
- Prior cardiac catheterization (dates, findings) 1, 7
- Prior stress testing (type, date, results) 1, 7, 6
- Prior echocardiography (findings, ejection fraction) 1
Recent Hospitalizations
- Recent admission for chest pain, ACS, or heart failure 1
- Recent immobilization or prolonged bed rest (PE risk factor) 4
- Recent procedures or surgeries (PE risk factor) 4
Family History
- Premature coronary artery disease (male first-degree relative <55 years, female first-degree relative <65 years) 1, 3, 2
- Sudden cardiac death in family members 1
- Familial hyperlipidemia 1
- Connective tissue disorders (Marfan syndrome, Ehlers-Danlos—aortic dissection risk) 3
Social History
- Tobacco use: current, former (pack-years), recent cessation 1, 3, 2
- Alcohol use: quantity, frequency (can potentiate hypotension with nitroglycerin) 5
- Illicit drug use: particularly cocaine, methamphetamine (ACS risk) 1
- Occupational exposures: industrial nitrates (tolerance and withdrawal risk) 5
- Exercise tolerance and recent changes 1
- Ability to perform activities of daily living 1
- Recent long-distance travel or prolonged sitting (PE risk factor) 4
Critical Documentation Note: In women presenting with chest pain, specifically document presence or absence of accompanying symptoms more common in female ACS patients: nausea, fatigue, dyspnea, jaw pain, and epigastric discomfort, as women are at risk for underdiagnosis 1, 3, 4. In patients ≥75 years, document presence or absence of atypical presentations including isolated dyspnea, syncope, acute delirium, or unexplained falls 1, 4.