History Taking 1
Chest Pain
Scenario
The patient is a 57-year-old male Mr. PS who complains of
pain in his chest.
The pain is retrosternal, radiates to his shoulder tip
and to his neck and tightening in nature. It is brought on by exertion
(walking about 100 yards, climbing a flight of stairs) and is relieved by
rest. The pain subsides in a few minutes when he stops exertion. It gradually
disappears. It can be quite severe and accompanied by sweating. The pain has
been present for approximately 3 months and is steadily getting worse with the
distance required to cause the pain decreasing.
The patient has no major illnesses although he had been
told by his GP that his blood pressure and cholesterol were on the high side.
He is not on any drugs at the moment
He smokes 20 cigarettes a day and takes 15 units of
alcohol a week
He has what he describes as a normal diet
He does not do any regular exercise
His father died of a heart attack at the age of 60
His brother who is 62 has had heart surgery following a
heart attack
He is an accountant, married with 3 children, lives in a
4 bed roomed house that has a flight of stairs
He believes that he has developed heart disease like his
father and brother and is expecting to have multiple tests and possibly an
operation like his brother
He is afraid that the disease has been brought on by
smoking and is also afraid that this illness may affect his capacity to work.
He is worried about the possibility that he could die of this illness, as his
children have still not finished full time education.
Salient Features
The salient features of this case are:
57 years old
Chest pain
Retrosternal with radiation to the shoulder and neck
Tightening in nature
Severe pain
May be accompanied by sweating
Brought on by exertion, relieved by rest
Pain steadily increasing in severity over last few months
Blood pressure and cholesterol high
Smokes
No regular exercise
Family history of ischaemic heart disease
Sedentary job
Believes he may have heart disease
Expectations of further tests and possibly surgery
Anxious about cause
Anxious about effects on ability to work
Anxious about survival
Approach
This history has a lot of information that is relevant to
the management of the case.
On the basis of the history alone it is possible to make
a diagnosis of ischaemic heart disease if all the features are obtained
In addition information relevant to the diagnosis is
obtained on asking details such as the past illnesses and family history
Very important information regarding the patient’s
beliefs, expectation and anxieties are also obtained when this aspect of
history taking is explored
If this information is elicited then you will score high
marks in the examination
To make sure that all this information is obtained it is
essential to have a robust method of history taking
Read ACES for PACES chapters
3 (diagnosis) and 4 (history taking) and learn the principles and
the method
Use the mnemonics given to aid recall and ensure
completeness of history taking ACES for PACES
pages 22 and24
Practice over and over again as this is the only way to
ensure success
Remember marks are awarded for each aspect of the history
and taking a complete history will ensure more marks than going into a few
aspects in detail
