Chest Pain
History OSCE Guide
Chest Pain is one of the classic OSCE History Stations. It is common, high yield and important because some causes of chest pain can be immediately serious.
What is this Station Testing?
In a chest pain history station, the examiner wants to see that you can:
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Explore the pain properly using SOCRATES
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Recognise dangerous causes, including ACS, PE, aortic dissection and pneumothorax
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Ask whether the pain is ongoing, worsening or different from usual
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Screen for associated symptoms such as breathlessness, sweating, nausea, collapse or haemoptysis
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Identify cardiovascular and PE risk factors
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Recognise when urgent assessment is needed
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Summarise the case clearly
A key question is whether exertional pain that used to settle with rest or GTN is now more severe, lasting longer or not settling.
Explore the Chest Pain Using SOCRATES
SITE
- Where exactly is the pain?
- Can you point to it?”
CHARACTER
- When did it start?
- Did it come on suddenly or gradually?
- What were you doing at the time?”
ASSOCIATED SYMPTOMS
- “Any shortness of breath, sweating, nausea, dizziness, palpitations, collapse, cough, fever, coughing blood or leg swelling?”
EXACERBATING AND RELIEVING FACTORS
- “Does anything bring it on or make it better? Does it improve with rest? Have you tried GTN?”
A very important question is:
“Is the pain still there now?”
Ongoing severe chest pain, sudden severe pain, pain radiating to the back, or pain with collapse, breathlessness or haemoptysis should prompt urgent assessment.
Start Open: "Can you tell me what has brought you in today?" Then use SOCRATES to explore the pain:
ONSET
- When did it start?
- Did it come on suddenly or gradually?
- What were you doing at the time?”
RADIATION
- Does it move anywhere else, such as the arm, jaw, neck or back?”
TIMING
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“Is it constant or does it come and go? How long does it last? Have you had this before?”
SEVERITY
- “On a scale of 0 to 10, how severe is it?”
Screen for wider Cardiovascular Symptoms
- After exploring the pain, screen for other cardiovascular symptoms.
Ask about:
- Shortness of breath
- Palpitations
- Dizziness
- Syncope or collapse
- Ankle swelling
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Reduced exercise tolerance
- Calf pain on walking
Chest Pain red flags
Important red flags include:
- Ongoing severe central chest pain
- Chest pain radiating to the arm, jaw or back
- Chest pain with sweating, nausea or breathlessness
- Syncope or collapse
- Sudden tearing pain through to the back
- Haemoptysis, pleuritic pain or unilateral calf swelling
- New neurological symptoms
- Severe breathlessness
- Hypotension or appearing acutely unwell
- Chest pain with a significant cardiac history
If the patient appears very unwell, do not continue as if this is a routine history. In real life, you would escalate, assess ABCDE, get an ECG and involve senior help.
- Also ask about relevant procedures, such as coronary stents, coronary artery bypass grafting, valve surgery, pacemaker or ICD.
Past Medical and Surgical History
Chest pain histories should include cardiovascular risk factors and relevant medical background.
Ask about:
Previous MI or angina
Hypertension
High cholesterol
Diabetes
Smoking and alcohol use
Chronic kidney disease
Stroke or TIA
Heart failure or atrial fibrillation
Family history of cardiovascular disease
Previous DVT or PE, if considering pulmonary embolism
- The aim is not to list every condition. It is to identify factors that increase the risk of serious chest pain, especially ACS or PE.
Drug History and Allergies
Ask about regular medications, over-the-counter treatments and allergies.
In a chest pain history, focus on:
Aspirin, clopidogrel or other antiplatelets
Anticoagulants, such as warfarin, apixaban or rivaroxaban
GTN spray
Blood pressure, cholesterol or diabetes medication
Hormonal contraception or HRT, if relevant
Anything taken for the pain today
Always clarify allergies and the reaction.
Family History
Ask about cardiovascular disease in the family.
“Is there any family history of heart attacks, angina, strokes or sudden cardiac death?”
If yes, clarify who was affected, their age and what happened.
Premature cardiovascular disease or sudden cardiac death is particularly important.
Social History
Social history helps you assess cardiovascular risk and the patient’s overall situation.
Ask about:
-Smoking
-Alcohol
-Recreational drugs, especially cocaine in younger patients with chest pain
-Diet and exercise
-Occupation
-Driving, especially if syncope or collapse is involved
-Living situation, baseline function and support at home
Useful questions include:
“Do you smoke?”
“What would you drink in a typical week?”
“Do you use any recreational drugs at all?”
“What do you do for work?”
“Is this affecting your normal activities?”
“Who is at home with you?”
Explore the Patient’s Ideas, Concerns and Expectations.
Explore the patient’s ideas, concerns and expectations.
Try to make this sound natural rather than robotic.
Example Summary:
“Mr Johnson is a 68-year-old man presenting with a one-hour history of central, heavy chest pain that came on while walking. The pain radiates to his left shoulder and jaw and is associated with shortness of breath and nausea. He has had similar exertional chest pain over the last few months which normally settled with rest, but this episode has not settled. His background includes hypertension and hypercholesterolaemia. He smokes heavily and has a family history of myocardial infarction. Overall, I would be concerned about acute coronary syndrome and would want to assess him urgently.”
Ask:
“Had you any thoughts yourself about what might be going on?”
“Is there anything in particular you’re worried this could be?”
“What were you hoping we might be able to do today?”
If the patient is worried it could be their heart, acknowledge this without false reassurance:
“I understand why you’re worried about that. I’m taking this seriously, and I’d want to assess you urgently and do some tests to work out what is going on.”
Avoid saying, “I’m sure it’s nothing,” before serious causes have been considered.
What to look out for in Chest Pain
Once you have explored the pain, try to link the symptoms together. In a chest pain history, you are not just collecting answers — you are looking for patterns that point towards serious causes.
Be concerned about acute coronary syndrome if the pain is:
- Central, heavy, tight or crushing
- Brought on by exertion
- Radiating to the arm, neck or jaw
- Associated with sweating, nausea, vomiting or breathlessness
- Occurring in someone with risk factors such as smoking, diabetes, hypertension, high cholesterol or a family history of heart disease
A particularly concerning story is chest pain that used to come on with exertion and settle with rest, but is now lasting longer, more severe, or not settling.
Acute Coronary Syndrome
Pneumothorax or Pneumonia
Respiratory causes become more likely when the chest pain is associated with:
- Pleuritic pain
- Shortness of breath
- Cough
- Fever
- Sputum
- Recent chest infection
A sudden onset of pleuritic pain and breathlessness may suggest pneumothorax. Fever, cough and sputum may point more towards infection.
Pulmonary Embolism
Think about pulmonary embolism when chest pain is associated with:
- Sudden shortness of breath
- Pleuritic pain, meaning pain worse on breathing in
- Haemoptysis
- Calf pain or unilateral leg swelling
- Recent surgery, immobility or long travel
- Previous DVT or PE
- Active cancer
- Hormonal contraception or HRT, where relevant
This is why symptoms like calf swelling or coughing blood matter in a chest pain history — they are not random questions
Aortic Dissection
Aortic dissection is less common, but important not to miss.
Look out for:
- Sudden, severe chest pain
- Tearing or ripping pain
- Pain radiating through to the back
- Collapse or neurological symptoms
- A history of hypertension or connective tissue disease
This is one of the reasons you should ask about the onset, character and radiation of the pain.
Pericarditis
Pericarditis often causes pain that is:
- Sharp
- Worse lying flat
- Improved by sitting forward or leaning forward
- Associated with a recent viral illness
This is a good example of why exacerbating and relieving factors can be so useful.
Gastro-Oesophageal or Musculoskeletal Pain
Not all chest pain is cardiac.
Reflux or oesophageal pain may be suggested by:
- Burning pain
- Acid reflux symptoms
- Pain related to meals
- Pain worse when lying flat
Musculoskeletal pain may be suggested by:
- Pain worse with movement
- Pain worse on palpation
- Recent injury, lifting or trauma
The key is to consider and rule out dangerous causes before settling on a less serious explanation.
Possible Examiner Questions & Model Answers
At the end of a chest pain history, the examiner may ask you some follow-up questions. These are usually designed to test your clinical reasoning after you have taken the history.
Q1: What are your top differential diagnoses?
“My main concern would be acute coronary syndrome, including myocardial infarction or unstable angina. Other important differentials would include pulmonary embolism, aortic dissection
A strong answer should put the most dangerous and most likely diagnoses first.
Q2: What features make you concerned about ACS?
Central heavy, tight or crushing chest pain, radiation to the arm, neck or jaw, pain brought on by exertion, pain not settling with rest, sweating, nausea, vomiting, breathlessness, previous angina symptoms and cardiovascular risk factors.
A particularly concerning history is chest pain that previously came on with exertion and settled with rest, but is now more severe, lasting longer or not settling.
Q3: What investigations would you request?
I would assess the patient urgently and start with observations, ECG and blood tests.
Useful investigations include 12-lead ECG, troponin repeated according to local protocol, FBC, U&Es, LFTs, CRP if infection or inflammation is possible, coagulation screen if relevant, chest X-ray, and D-dimer or CTPA if PE is suspected.
The key investigation for suspected ACS is an ECG, followed by troponin testing.
Q4: What are cardiovascular risk factors?
Modifiable risk factors include smoking, hypertension, high cholesterol, diabetes control, diet, exercise, alcohol intake and weight.
Non-modifiable risk factors include age, sex, family history and ethnicity depending on the population and context.
Q5: How would you manage this patient initially?
If I was concerned about ACS, I would treat this as an emergency.
I would assess using ABCDE, check observations, get senior help, perform an urgent ECG, gain IV access, send bloods including troponin, give pain relief, anti-emetic if needed, oxygen only if hypoxic, and follow local ACS guidance.
Quick Chest Pain History Structure
A focused chest pain history can be structured around:
Explore the pain using SOCRATES
Ask associated symptoms, including SOB, sweating, nausea, palpitations and syncope
Screen for serious causes, including ACS, PE, dissection and pneumothorax
Ask about cardiovascular risk factors
Ask about PMH, medications and allergies
Ask about family and social history
Explore ICE
Summarise and escalate if concerned
Key Message
A strong chest pain history is not just about asking SOCRATES.
It is about recognising risk.
Explore the pain properly, ask about associated cardiovascular symptoms, screen for serious causes, identify risk factors and respond to the patient’s concerns.
In an OSCE, that shows the examiner you are not just taking a history — you are thinking like a safe clinician.