Section L Chest pain

Nov 18, 2025
3 min read

Index

Introduction
Understanding the Significance of Chest Pain
Comprehensive History-Taking
Clinical Examination: Identifying Red Flags
Essential Investigations
Formulating a Differential Diagnosis
Initial Management and Prioritisation
Recording Findings and Ensuring Continuity of Care
Clinical Reflections and Skills Gained
Conclusion
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1. Introduction

Chest pain remains one of the most challenging and time-critical presentations encountered across clinical environments — from offshore vessels to remote industrial sites and traditional healthcare settings. Managing it effectively requires structured thinking, sound clinical judgement, and the confidence to act quickly.

At Kraken Medical, we focus on equipping clinicians and remote medics with the skills and decision-making frameworks needed to assess, stabilise, and escalate chest pain cases safely. This reflective piece synthesises previously gained knowledge and clinical competencies, illustrating a best-practice approach to managing chest pain from first contact to ongoing documentation.

2. Understanding the Significance of Chest Pain

Chest pain is not a diagnosis — it is a symptom with a wide spectrum of potential causes, from benign musculoskeletal strain to life-threatening myocardial infarction. The clinician’s task is to rapidly identify whether the pain is cardiac, respiratory, musculoskeletal, or gastrointestinal in origin, while maintaining a high index of suspicion for time-critical conditions.

A structured approach reduces uncertainty, enhances patient safety, and ensures timely intervention.

3. Comprehensive History-Taking

History-taking forms the backbone of chest pain assessment. A focused but thorough history can significantly narrow diagnostic uncertainty.

Key components include:

Pain characteristics:Nature (sharp, dull, crushing, burning), intensity, onset, duration, progression.
Radiation:Pain extending to the jaw, arm, back, or epigastrium increases suspicion of cardiac pathology.
Associated symptoms:Shortness of breath, diaphoresis, nausea, palpitations, dizziness, presyncope.
Exacerbating/relieving factors:Does pain relate to exertion, respiration, position, meals, or stress?
Risk factors:Smoking, hypertension, diabetes, hyperlipidaemia, family history, recent illness, trauma.
Previous episodes:Including known angina, previous cardiac events, or known respiratory conditions.

A clear patient narrative often provides the earliest clues to the underlying pathology.

4. Clinical Examination: Identifying Red Flags

A systematic examination helps to assess severity and determine whether the patient is stable.

Vital signs

Heart rate, respiratory rate, blood pressure, temperature and oxygen saturation identify immediate threats such as arrhythmia, shock, or respiratory compromise.

Cardiovascular assessment

Heart sounds
Pulse quality and equality
Peripheral perfusion

Respiratory assessment

Lung auscultation for crackles, wheeze, reduced air entry
Assessment for signs of pneumothorax, infection, or pulmonary oedema

Chest wall assessment

Palpation for tenderness
Detection of crepitus or deformity

Examination findings help differentiate between cardiac and non-cardiac causes while guiding investigation priorities.

5. Essential Investigations

While immediate management may begin before results return, investigations play a crucial role in confirming or excluding life-threatening causes.

Core investigations include:

Electrocardiogram (ECG)Critical for detecting myocardial ischaemia, infarction, arrhythmias, and conduction abnormalities.
Blood testsParticularly cardiac biomarkers (e.g., troponin) to identify myocardial injury. Additional tests may include FBC, U&E, and inflammatory markers depending on context.
Chest X-rayUseful for identifying pneumothorax, pneumonia, cardiomegaly, or fluid overload.
Point-of-care testing (POCT)Such as lactate or D-dimer (if available), offering further diagnostic insight.

These investigations work in conjunction with history and examination to clarify the clinical picture.

6. Formulating a Differential Diagnosis

A broad differential diagnosis ensures important conditions are not missed.

Cardiac causes

Acute coronary syndrome (ACS)
Angina
Pericarditis
Aortic dissection (rare but critical)

Respiratory causes

Pneumothorax
Pulmonary embolism
Pneumonia or pleuritis

Gastrointestinal causes

Gastro-oesophageal reflux disease (GORD)
Oesophageal spasm
Peptic ulcer disease

Musculoskeletal and other causes

Costochondritis
Trauma
Anxiety-related chest discomfort

Recognition of red flags helps prioritise urgent management while ruling out high-risk diagnoses.

7. Initial Management and Prioritisation

Initial treatment depends on the suspected cause but often starts with stabilisation and symptom relief.

Cardiac-suspected chest pain

Ensure high-flow oxygen if saturation is low
Aspirin (unless contraindicated)
Glyceryl trinitrate (GTN) for suspected angina/ACS if blood pressure allows
Pain management (e.g., morphine if indicated)
Preparation for evacuation or further medical support if required

Non-cardiac causes

Analgesia for musculoskeletal pain
Anti-inflammatory therapy for pleuritic pain
Proton pump inhibitors for suspected reflux
Supportive measures for anxiety-related symptoms

Regardless of cause, continuous monitoring and reassessment are essential.

8. Recording Findings and Ensuring Continuity of Care

Accurate, structured documentation is essential for safe clinical practice.

Records should include:

History (including onset, characteristics, associated symptoms)
Vital signs and examination findings
ECG interpretation
Results of investigations
Working diagnosis and differential
Treatments administered and patient response
Communication with senior clinicians or emergency services

Clear documentation supports seamless care handover and medico-legal compliance.

9. Clinical Reflections and Skills Gained

Managing chest pain reinforces several core clinical competencies:

Structured thinking under pressure
Confidence in ECG interpretation
Prioritisation of life-threatening conditions
Enhanced communication with patients during distressing symptoms
Collaborative working with senior clinicians and emergency pathways
Commitment to thorough documentation

These skills ensure that patient safety remains central to every decision.

10. Conclusion

Chest pain remains a high-risk presentation requiring swift, structured, and evidence-based assessment. By integrating strong history-taking, focused examination, appropriate investigation, and thoughtful differential diagnosis, clinicians can deliver safe and effective early management.