CCFP priority topic 13 of 105
Chest Pain on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 22, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Chest Pain. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
The history
Ask the questions that turn new chest pain into one likely cause.
CFPC skill Clinical reasoningPhase History
On the exam
A 9-year-old with sickle cell disease, in hospital on opioids for a pain crisis, has new chest pain. Expect a short menu (pick several from a list).
Pick the history that finds the cause.
Common mistakes
Asking about an uncle's heart attack, or about reflux and exercise. None of it explains new pain after days in bed on opioids. Ask about the lung first.
Approach
- Ask how it started: sudden and at its worst at once, or building over hours.
- Ask what it feels like: pressure, tearing, sharp with each breath, or burning.
- Ask what brings it on and what eases it: effort and rest, breathing, position, meals, swallowing.
- Ask what comes with it: breathlessness, sweating, fainting, fever, cough, a rash.
- Ask about heart risks: smoking, diabetes, blood pressure, cholesterol, early heart disease in the family, cocaine.
- Ask about clot risks: recent surgery, bed rest, cancer, pregnancy, estrogen, a past clot.
- In a child, ask about sickle cell disease, asthma and recent illness. Chest wall strain is common, but it comes last when the story points elsewhere.
| Pattern | Think of | Ask also |
|---|---|---|
| Pressure with effort, eased by rest | Angina or a heart attack | Sweating, breathlessness, heart risks |
| Tearing pain to the back, worst at onset | Aortic dissection (a tear in the main artery) | High blood pressure, fainting, a weaker pulse in one arm |
| Sharp with each breath, sudden breathlessness | Pulmonary embolism or a collapsed lung | Clot risks, recent surgery, smoking |
| Sharp, worse lying flat, better sitting forward | Pericarditis (inflamed sac around the heart) | A recent viral illness |
| Burning in a band on one side | Shingles (herpes zoster) | Older age, weak immunity, a rash starting |
Key feature 2 of 5
Treat first
When chest pain could kill, start treatment while the tests are still running.
CFPC skill SelectivityPhase Diagnosis, treatment
On the exam
A 6-week-old on high-flow oxygen suddenly screams, with one-sided chest signs and falling oxygen. Expect one best answer.
Pick the first step, then the plan before transfer.
Common mistakes
Putting in a breathing tube first, or giving a fluid bolus. Pushed air makes a tension pneumothorax worse, and fluid buys little while air stays trapped.
Approach
- Think of four killers: tension pneumothorax (trapped air in the chest pressing on the heart and lungs), cardiac tamponade (fluid squeezing the heart), aortic dissection and pulmonary embolism. Each can need action before the scan.
- Tension pneumothorax: one side quiet, oxygen falling, signs of shock.
- Breathing support may be needed too, but it does not release the air. Pushing air into the lungs can enlarge the tension.
- Possible dissection: call the surgical team and get imaging now.
- Possible tamponade: low blood pressure, swollen neck veins and quiet heart sounds. Call for urgent drainage of the fluid.
Key feature 3 of 5
Rule out the heart
In chest pain with no clear cause, exclude a heart cause before anything else.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, investigationSources Choosing Wisely Canada
On the exam
A 52-year-old smoker has vague chest discomfort and a normal first electrocardiogram (ECG). Expect a short menu (pick several from a list).
Pick the tests that rule out a heart cause.
Common mistakes
Sending the patient home after one normal ECG, or calling it reflux because an antacid helped. Ordering myoglobin or creatine kinase-MB (CK-MB) instead of troponin is wrong too.
Approach
- Measure troponin I or T. Unlike CK-MB and myoglobin, it is specific to heart injury. Skip those two tests.
- Relief from an antacid or from nitroglycerin does not settle the cause.
- Expect vague or unusual pain in women, older adults and people with diabetes. It should not lower your guard.
- Move on to the gut, the chest wall or the skin only once the heart is excluded.
Key feature 4 of 5
Gut, skin and infection
Recognize chest pain from shingles, the gullet, an ulcer or infection, then confirm it.
CFPC skill Clinical reasoningPhase Diagnosis, investigationSources Choosing Wisely Canada, Canadian Paediatric Society 2022
On the exam
A 45-year-old has gnawing, burning pain high in the belly after meals. The heart is already excluded. Expect one best answer.
Name the cause and pick the next step.
Common mistakes
An upper gastrointestinal series (a barium x-ray), or endoscopy under 60 with no alarm features. Start with a proton pump inhibitor (PPI) trial or a test for Helicobacter pylori (a stomach bacterium that causes ulcers).
Approach
- Reflux or a hiatal hernia (part of the stomach pushed up into the chest): burning behind the breastbone, worse after meals or lying down, a sour taste.
- Ulcer: gnawing pain high in the belly, linked to meals or to anti-inflammatory drugs.
- Under 60 with no alarm features: try a PPI or a non-invasive test for Helicobacter pylori. Do not start with endoscopy.
- Alarm features can call for endoscopy: worsening trouble swallowing, anemia or weight loss.
- For indigestion (dyspepsia), skip an upper gastrointestinal (GI) series, a barium x-ray of the stomach. It gives many false positives and false negatives.
- Shingles: burning or tingling in a band on one side of the chest. The pain can come before the rash, so look at the skin again.
- Infection: fever, cough and crackles at one base point to pneumonia. In sickle cell disease, think of acute chest syndrome: a new lung shadow with fever and breathing signs.
- Acute chest syndrome: admit. Start broad-spectrum antibiotics, a third-generation cephalosporin plus a macrolide to cover Mycoplasma (a pneumonia germ). Do not wait for test results.
Key feature 5 of 5
Pulmonary embolism
When a clot in the lung is suspected, never let a weak test clear it, and treat at once.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, diagnosis, treatmentSources Choosing Wisely Canada, BC Guidelines 2024
On the exam
A 34-year-old on birth control pills has sudden sharp pain with each breath, a fast pulse and a clear x-ray. Expect a short menu (pick several from a list).
Pick the tests and the first treatment.
Common mistakes
Clearing the clot on a normal x-ray, ECG or oxygen level. Or ordering a computed tomography (CT) scan before scoring with a decision rule and, where needed, a D-dimer (a blood test for clot breakdown).
Approach
- Score the chance of a clot first with the Wells score. Use the PERC rule (pulmonary embolism rule-out criteria) only when the Wells score says a clot is unlikely.
- Get a D-dimer where the rule calls for it.
- Order computed tomography (CT) pulmonary angiography or a ventilation-perfusion (VQ) scan only after that step. Both carry radiation, and CT needs contrast.
- In pregnancy or a clotting disorder, the rules are not validated. Use clinical judgment.
- A normal oxygen level, ECG or chest x-ray does not rule out a clot.
- Clot likely on the Wells score: start an anticoagulant (blood thinner) while you wait for the scan.
- Clots are rare in children without a central line. Look hard for another cause first.
| Test | What it can do | What it cannot do |
|---|---|---|
| Chest x-ray | Find a collapsed lung or pneumonia | Rule out a clot |
| ECG | Find a heart attack or heart strain | Rule out a clot |
| D-dimer | Help rule out a clot when the chance is low | Prove a clot; it rises with infection, cancer and pregnancy |
| CT pulmonary angiography | Confirm or exclude a clot | Replace the decision rule as the first step |
Flashcards
Answer it first, then check.
KF 1Sharp chest pain, worse lying flat and better sitting forward. What do you suspect?
Pericarditis. Ask about a recent viral illness and get an ECG.
KF 2Sudden chest pain, one quiet side, falling oxygen and shock. What do you suspect?
Tension pneumothorax: trapped air in the chest pressing on the heart and lungs.
KF 2Low blood pressure, swollen neck veins and quiet heart sounds. What do you suspect?
Cardiac tamponade, fluid squeezing the heart. Call for urgent drainage of the fluid.
KF 3Which blood test shows heart injury in chest pain?
Troponin I or T. It is specific to heart injury, so skip myoglobin and CK-MB. Source: Choosing Wisely Canada
KF 4Burning pain high in the belly after meals at 45, heart excluded, no alarm features. Next step?
A PPI trial or a non-invasive Helicobacter pylori test. Under 60 without alarm features, skip endoscopy. Source: Choosing Wisely Canada
KF 4Burning pain in a band on one side of the chest, no rash yet. What is it?
Think of shingles. The pain can come before the rash, so look at the skin again.
KF 5A stable adult may have a lung clot. What comes before the CT?
The Wells score first, and PERC only if a clot is unlikely. Then a D-dimer where the rule calls for it. Source: Choosing Wisely Canada, BC Guidelines 2024
KF 5A clot is likely on the Wells score, and the CT is hours away. Now what?
Start a blood thinner now. Do not wait for the scan to confirm the clot. Source: BC Guidelines 2024
FAQ
Does a normal ECG rule out a heart attack?
No. One normal tracing does not exclude it. Unexplained chest pain stays a possible heart problem until a heart cause is ruled out. Keep looking while the story fits.
Should every patient with chest pain get a D-dimer?
No. Score the chance of a clot first with a decision rule. Use the D-dimer only where the rule calls for it. In pregnancy, the rules are not validated.
Are chest pain cases only about adults?
No. Infants and children appear too. Chest wall strain is common in children, but fever, low oxygen or sickle cell disease send you to the lung first.
Should healthy adults get a screening ECG?
No. Choosing Wisely Canada advises against screening ECGs and chest x-rays in low-risk people without symptoms. A patient with chest pain has a symptom, so that advice does not apply.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 22, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Acute complications in children with sickle cell disease: Prevention and managementCanadian Paediatric Society · 2022
- Venous Thromboembolism - Diagnosis and ManagementBC Guidelines · 2024