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
- Ask where the pain is:
“Where exactly is the pain?”
“Can you point to where you feel it?”
Cardiac pain is often central or left-sided, but patients may describe it differently.
CHARACTER
- Ask what the pain feels like.
“How would you describe the pain?”
Cardiac pain is often described as heavy, tight, crushing or pressure-like.
ASSOCIATED SYMPTOMS
- Ask if there were any other symptoms with the pain.
“Did you have any other symptoms with it?”
Important associated symptoms include:
- Shortness of breath
- Sweating
- Nausea or vomiting
- Palpitations
- Dizziness or collapse
- Cough
- Haemoptysis
- Fever
- Calf pain or leg swelling
These questions help you move beyond “chest pain” and start thinking about the differential diagnosis.
EXACERBATING AND RELIEVING FACTORS
- Ask what brings the pain on and what improves it.
“Does anything bring the pain on?”
“Does anything make it better?”
“Does it improve with rest?”
“Have you taken anything for it, such as GTN?”
Pain brought on by exertion and relieved by rest is typical of angina. Pain that previously settled with rest but now does not settle is concerning for unstable angina or myocardial infarction.
OSCE TALK TIP
In chest pain, one of the most important things to clarify is whether this episode is different from previous episodes.
For example:
“Have you had this pain before?”
“What normally brings it on?”
“What normally makes it settle?”
“Is this episode lasting longer than usual?”
A history of exertional chest pain that previously settled with rest, but is now more severe, lasting longer, or not settling, should make you think about unstable angina or myocardial infarction.
ONSET
- Ask when it started and what the patient was doing at the time.
“When did it start?”
“Did it come on suddenly or gradually?”
“What were you doing when it started?”
Pain that comes on during exertion is important. Sudden severe pain should make you think carefully about serious causes.
RADIATION
- Ask if the pain moves anywhere else.
“Does the pain move anywhere else?”
Cardiac pain may radiate to the left arm, both arms, neck, jaw or back.
Pain radiating through to the back can also be important when thinking about aortic dissection.
TIMING
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Ask whether the pain is constant or intermittent.
“Is the pain there all the time or does it come and go?”
“How long does it last?”
“Have you had pain like this before?”
This is where you should ask about previous episodes of exertional chest pain that settled with rest, as this may suggest angina.
A very important question is:
“Is the pain still there now?”
Ongoing severe chest pain is much more concerning and should prompt urgent assessment.
SEVERITY
- Ask the patient to score the pain.
“On a scale of 0 to 10, how severe is the pain?”
If the patient is in severe pain, acknowledge it. In a real clinical setting, you would want to assess them urgently, get senior help if needed and provide pain relief.
For example:
“That sounds very painful. I’d want to make sure we get you assessed quickly and get you something to help with the pain.”
[TOGGLE START: Do not forget these questions]
Ask Key Cardiovascular Associated 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
For Example:
“Have you had any shortness of breath?”
“Have you noticed your heart racing or beating irregularly?”
“Have you had any dizziness, faints or funny turns?”
“Have you noticed any swelling in your ankles?”
“Do you ever get short of breath lying flat, or wake up short of breath at night?”
“Do you ever get pain in your calves when walking that improves with rest?”
You do not need to ask every cardiovascular question in exactly the same way every time. The important thing is that you are actively thinking about what else could be going on
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.
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.
Cardiovascular risk factors
Chest pain histories should always include cardiovascular risk factors.
Ask about:
- Hypertension
- High cholesterol
- Diabetes
- Smoking
- Family history of cardiovascular disease
- Obesity
- Chronic kidney disease
- Previous angina, MI, stroke or peripheral vascular disease
You can think of these as modifiable and non-modifiable risk factors.
Modifiable Risks
- These are risk factors we may be able to change or improve:
- Smoking
- High blood pressure
- High cholesterol
- Diabetes control
- Diet
- Exercise
- Alcohol intake
- Weight
Non-Modifiable Risks
- These are risk factors we may be able to change or improve:
- Smoking
- High blood pressure
- High cholesterol
- Diabetes control
- Diet
- Exercise
- Alcohol intake
- Weight
Past Medical and Surgical History
After exploring the chest pain, ask about the patient’s medical background.
Start generally:
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“Do you have any medical conditions?”
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“Have you ever been in hospital or had any operations?”
Then focus on the conditions that matter in a chest pain history.
In particular, ask about:
- Previous heart attack or angina
- High blood pressure
- High cholesterol
- Diabetes
- Stroke or TIA
- Heart failure
- Atrial fibrillation
- Previous DVT or PE, if you are considering pulmonary embolism
You may also ask about Relevant Procedures:
- Coronary stents
- Coronary artery bypass grafting
- Valve surgery
- Pacemaker or ICD
- You do not need to list every condition in medicine.
- The aim is to identify background conditions that increase the chance of serious causes of chest pain, especially acute coronary syndrome or pulmonary embolism.
Drug History and Allergies
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Ask generally:
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Then ask a few focused questions that are relevant to chest pain.
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“Do you take anything over the counter or from the pharmacy?”
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“Do you take any regular medications?”
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For example:
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Are they on aspirin, clopidogrel or another antiplatelet?
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Are they on a blood thinner, such as warfarin, apixaban or rivaroxaban?
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Do they use a GTN spray?
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Have they taken anything for the pain today?
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Are they on medication for blood pressure, cholesterol or diabetes?
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If relevant, are they on hormonal contraception or HRT?
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Allergies
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“Do you have any allergies?”
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If yes, clarify the reaction:
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“What happens when you take it?”
Family History
Ask about family history of cardiovascular disease.
“Is there any family history of heart attacks, angina, strokes or sudden cardiac death?”
If yes, clarify:
Which relative?
What age were they?
What happened?
A family history of premature cardiovascular disease is particularly important.
For example:
“How old was your father when he had his heart attack?”
“Was there anyone in the family who died suddenly at a young age?”
Ask sensitively if a relative has died.
For example:
“I’m sorry to hear that. Do you mind me asking how old they were when that happened?”
Social History
Social history is very important helper for understanding both cardiovascular risk and the patient’s overall situation.
Ask about:
Living situation
Baseline function
Smoking
Alcohol
Recreational drugs
Diet
Exercise
Occupation
Driving, especially if syncope or collapse is involved
Smoking
Ask if they smoke, how much they smoke and how long they have smoked for.
For example:
“Do you smoke at all?”
“How many cigarettes would you smoke in a day?”
“How many years have you smoked for? ”
You can calculate pack years if needed.
Alcohol
Ask about their usual weekly alcohol intake.
“What would you drink in a typical week?”
Recreational Drugs
Ask about recreational drugs where relevant, especially in younger patients with chest pain.
Cocaine is particularly important because it can cause coronary artery spasm and chest pain.
A simple way to ask is:
“Do you use any recreational drugs at all?”
Diet and Exercise
Ask about diet and physical activity.
“What would your diet be like day to day?”
“Do you do much exercise?”
These questions help assess cardiovascular risk and can be useful later when discussing prevention
Occupation and Function
Ask what the patient does for work and whether symptoms are affecting their normal activities.
For older patients, also ask about baseline function and support at home.
“Who is at home with you?”
“How do you normally manage day to day?”
“Are you usually independent?”
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:
Here is an example of how you might summarise a concerning chest pain history:
“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.”
A good summary should include:
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Who the patient is
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What the presenting complaint is
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Key positive features
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Key risk factors
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Important negatives, if relevant
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Your main concern or likely differential
For Example:
“I’ve been listening to everything you’ve said, and I can understand why this is worrying. 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 for you today?”
If the patient says they are worried it is their heart, acknowledge that.
For example:
“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.”
That can sound reassuring, but it may be unsafe before serious causes have been considered.
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 is your most likely diagnosis?
“This would depend on the history. If the patient had central crushing chest pain radiating to the arm or jaw, associated with sweating, nausea or breathlessness, especially with cardiovascular risk factors, my main concern would be acute coronary syndrome.”
Q3: How would you explore cardiovascular risk factors during the history taking?
What features make you concerned about acute coronary syndrome?
Features that would make you concerned include:
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Central heavy, tight or crushing chest pain
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Radiation to the arm, neck or jaw
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Pain brought on by exertion
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Pain not settling with rest
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Sweating
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Nausea or vomiting
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Breathlessness
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Previous angina symptoms
Cardiovascular risk factors such as smoking, diabetes, hypertension, high cholesterol or family history
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.
Q4: What investigations would you request?
“I would assess the patient urgently and start with observations, an ECG and blood tests.”
Useful investigations include:
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Full set of observations
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12-lead ECG
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Troponin, repeated according to local protocol
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Full blood count
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Urea and electrolytes
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Liver function tests
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CRP if infection or inflammation is possible
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Coagulation screen if anticoagulation or procedures may be needed
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Chest X-ray
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Consider D-dimer or CTPA if pulmonary embolism is suspected
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Consider arterial or venous blood gas if the patient is unwell or hypoxic
In an OSCE, the key investigation for suspected acute coronary syndrome is an ECG, followed by troponin testing.
Q5: What are modifiable and non-modifiable cardiovascular risk factors? Explain the features that differentiate stable angina from unstable angina.
Modifiable risk factors are things we may be able to change or improve.
Examples include:
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Smoking
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Hypertension
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High cholesterol
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Diabetes control
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Diet
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Exercise
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Alcohol intake
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Weight
Non-modifiable risk factors are things we cannot change.
Examples include:
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Age
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Sex
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Family history
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Ethnicity, depending on the population and context
Q6: How would you manage this patient initially?
“If I was concerned about acute coronary syndrome, I would treat this as an emergency. I would assess the patient using an ABCDE approach, check observations, get senior help, perform an ECG and follow local ACS guidance.”
Initial management may include:
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ABCDE assessment
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Full observations
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Urgent 12-lead ECG
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IV access and bloods, including troponin
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Pain relief
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Anti-emetic if nauseated
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Oxygen only if hypoxic
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Antiplatelet therapy if ACS is suspected and not contraindicated
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Cardiology or emergency medicine senior review
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Continuous monitoring if unstable
You do not need to give a full ACS protocol in a history station, but you should show that you recognise this could be urgent.
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.