01.11 Chest pain
Clerking for chest pain
PC: Chest pain
HPC:
SOCRATES
Associated with
Cardiac: Palpitations, dyspnoea, clamminess/nausea, LOC
Respiratory: Dyspnoea, cough/sputum/haemoptysis, wheeze
Other: Fever
PMH:
DHx:
Allergies:
FHx:
Cardiac conditions – MI / sudden death
SHx:
Smoking –
Alcohol –
Illicit drug use –
Lives with
iADL
O/E:
Obs: NEWS
Ix:
Bloods: ** trops, D-dimer,
VBG:
ECG:
CXR:
Echo:
Other imaging:
Imp:
Plan
Other notes
SOCRACTES
Site
Onset – what were they doing when pain started?
Character
Radiation
Associated with
Timing – timeline of pain (when did it reach maximal severity?)
Exacerbated by / alleviated by
Severity – _/10
Character
Crushing – possibly MI
Sharp / pleuritic – ?PE ?pneumonia
Tearing – ?aortic dissection
Can you point to it with one finger? / Reproducible pain – ?MSK
Radiation
Up the left arm / to the jaw – ?MI
Sudden onset radiating to the back – need to r/o aortic dissection
Associated with
Sweating, nausea, clamminess, dyspnoea – ?ACS (STEMI/NSTEMI/unstable angina) vs ?angina
Dyspnoea – ?MI ?pneumonia ?asthma/COPD
LOC – ?aortic stenosis
Cough/sputum – ?pneumonia
Haemoptysis – ?PE
Fever – ?pneumonia ?pericarditis
Exacerbated by
Deep inspiration – ?PE ?pneumonia ?pneumothorax ?MSK (eg costochondritis)
Lying down – ?pericarditis ?GORD (esp after eating)
Movement / reproducible pain on palpation – ?MSK
Exercise / exertion – ?stable angina
Alleviated by
GTN spray – ?ACS ?stable angina ?oesophageal spasm
Leaning forward – ?pericarditis (classically)
Investigations
Bedside – obs, ECG (± repeat ECG)
Bloods – troponin (including repeat trops), D-dimers, FBC/CRP (for pneumonia)
Imaging – CXR, perfusion angiogram / PCI (for ACS), CT angiogram (to r/o aortic dissection), CTPA (for PE), echo (for pericarditis / pericardial effusion)
Differential diagnoses
Cardiac
Acute coronary syndrome: STEMI, NSTEMI, unstable angina
Pericarditis, myocarditis, pericardial effusion
Aortic dissection, thoracic aortic aneurysm
Respiratory
Pneumonia, pleural effusion
Pneumothorax
Pulmonary embolism
MSK
Injury / trauma
Costochondritis
Gastro
GORD, oesophageal spasm
Pancreatitis (if pt is mistaking epigastric pain for chest pain)
Further reading
Bellolio F, Gottlieb M, Body R, Than MP, Hess EP. Evaluating patients with chest pain in the emergency department. BMJ 2025:r136. https://doi.org/10.1136/bmj.r136.
