Chest Pain Station

Author – Ansaam El-Sherif  Editor – James Mackintosh 

Last updated 04/02/24

Table of Contents

How to Use


  1. Read the brief below (1 minute). 
  2. Take a history (6 minute).
  3. Answer viva questions (3 minute).


  1. Familiarise yourself with the history & examination findings 
  2. After completing the history, viva the candidate

Candidate Brief

Alice is a 35 year old woman presenting to A&E with chest pain. Please take a history, carry out a focussed examination and answer the questions that follow.

Presenting Complaint

'SOCRATES' is useful for assessing pain-related presenting complaints.

  • Site – left sided
  • Onset – started the previous day, patient can’t remember if this is sudden or gradual.
  • Character – sharp
  • Radiation – along the left side of the chest
  • Associated symptoms – cough
    • Further details should only be provided if the candidate enquires further.
    • The cough started at around the same time as the chest pain. Initially was non-productive, but today has noticed some blood.
  • Timing – present since the previous day
  • Exacerbating/ Relieving factors – worse on inspiration, nothing has made the pain better
  • Severity – 7/10

Systems Review

  • Red flags: no fever, no weight loss, no night sweats
  • Cardiac: no palpitations, no syncope, right leg is swollen and red
  • Respiratory: some shortness of breath which has been progressing since arriving at A&E

Previous Medical History

  • Coeliac disease


  • Combined oral contraceptive pill. Started 15 years ago.


  • None

Social History

  • Works as a primary school teacher
  • Came back by plane from a holiday in Australia last week
  • Smokes 5 cigarettes a day for the last 10 years

Family History

  • Grandmother had a stroke at the age of 67


  • Ideas – doesn’t know what’s going on, but coughing up blood isn’t a good sign?
  • Concerns – since coughing up blood is concerned this could be something serious and life-threatening.
  • Expectations – nothing specific. Candidate should notice the anxiety and address this.


  • Temperature -  36.5°C
  • Heart Rate - 57
  • SpO2 -  92%
  • BP - 130/87
  • Respiratory Rate - 28


  • General – comfortable at rest
  • Hands – normal Capillary Refill Time, no clubbing, no CO2 retention flap
  • Face – no conjunctival pallor, no cyanosis
  • JVP - normal
  • Legs - Right leg is red and more swollen than the left.
  • Chest - No scars


  • Trachea central
  • Chest expansion equal


  • Normal percussion


  • Normal breath sounds
  • No evidence of added sounds such as wheeze or crackles


1. What are your key differential diagnoses?

  • Pulmonary embolism: The patient is describing a typical history of chest pain of a pleuritic nature, haemoptysis and shortness of breath. A history of COCP use and long-haul air travel combined with a swollen leg should raise suspicion of a DVT precipitant to the episode (1,2).
  • Pneumonia: could be an atypical history of pneumonia, however in the absence of fever or a cough productive of sputum this is less likely than a pulmonary embolism (3).
  • Musculoskeletal chest pain: should only be considered when other causes have been ruled out.

2. Please interpret the following ABG.

ABG Results

pH = 7.48

PaO2 = 7.3kPa

PaCO2 = 4.3kPa

HCO3- = 23 mEq/L

Base Excess = 0 mmol/L

  • This ABG shows type 1 respiratory failure (hypoxia and normocapnia) in addition to respiratory alkalosis. This is in keeping with a pulmonary embolism causing hypoxia and hyperventilation (4).

3. Please calculate this patient’s Wells score.

  • Full Wells score can be found in NICE thromboembolic guidelines (5,6)
  • Wells score = 7 (DVT signs and symptoms + Alternative diagnosis less likely + Haemoptysis).

4. What would be the initial steps of management based on the Wells score?

  • As the patient scores more than 4 points, a CTPA should be ordered and D-dimer should not be used initially (5, 7).
  • NICE guidelines recommend first line treatment should be a DOAC (unless contra-indicated) (5).

5. How long should treatment be continued for?

  • If a DVT or PE is provoked (e.g. following a period of immobilisation after surgery which has since resolved) then treatment should be continued for 3 months.
  • NICE guidelines suggest treatment should continue for longer if the PE is unprovoked (5).

6. What are the classical ECG findings associated with a pulmonary embolism?

  • Tachycardia
  • S1Q3T3 – this refers to the presence of S waves in ECG lead 1, combined with lead 3 Q waves and T wave inversion (1,8).
  1. National Institute for Health and Care Excellence. Pulmonary embolism [Internet]. NICE; 2022 [revised 2022 March; cited 2023 March 23]. (CKS). Available from:
  2. Weegenaar C. Pulmonary Embolism (PE) Acute Management ABCDE [Internet]Geeky Medics; 2022 [updated 2022 Jul 6; cited 2023 March 23]. Available from:
  3. National Institute for Health and Care Excellence. Chest pain [Internet]. NICE; 2022 [revised 2022 August; cited 2023 March 23]. (CKS). Available from:
  4. Zaininger P. ABG interpretation [Internet]. Geeky medics; 2022 [updated 2022 Oct 24; cited 2023 March 23]. Available from:
  5. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing [Internet]. NICE; 2020 [published 2020 March 26; cited 2023 March 23]. (clinical guideline [No.NG158]). Available from:
  6. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 2000 Mar;83(3):416-420.
  7. Freund Y, Cohen-Aubert F. Bloom B. Acute Pulmonary Embolism: A Review. JAMA. 2022 Oct 4;328(13):1336-45.
  8. Burns E. and Buttner R. ECG changes in Pulmonary Embolism [Internet]. Life in the Fast Lane; 2021 [updated 2021 Nov 30; cited 2023 March 23]. Available from:

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