Central Chest Pain in a 55-Year-Old Woman

Instructions

You are the ST4 in majors. A 55-year-old woman, Maggie, has self-presented to the ED with a 90-minute history of central chest pain. She was referred to you by the triage nurse for assessment.

Triage observations: HR 90 bpm, BP 145/85 mmHg, SpO₂ 97% on room air, RR 18, GCS 15, afebrile. An ECG obtained at triage shows normal sinus rhythm with no obvious acute changes. A brief triage note is available. No prior attendances are on file.

The examiner will remain silent throughout. An actor is playing Maggie and will respond to your questions. You are alone with the patient — there is no nurse or other clinician present. You have 8 minutes to take a focused history and explain your differential and plan. The examiner will not prompt you.

Equipment & setting

No equipment notes provided.

Actor / patient brief

Opening line: I've had this pain in the middle of my chest for about an hour and a half now. It feels really heavy, like someone's sitting on my chest. I'm sweating and I feel a bit sick. I didn't know what to do so my husband drove me straight here.

Character: Maggie, 55, recently retired primary school teacher. Lives with her husband in a semi-detached house. Her mother died of a heart attack aged 58; her father had coronary bypass surgery aged 60.

Hidden concern: Maggie is terrified she is having a heart attack identical to the one that killed her mother at 58. She has not volunteered this because she is frightened of the answer.

Behaviour: Visibly anxious — wrings hands, occasionally tearful. If the candidate is warm, introduces themselves, and addresses her fear directly after eliciting ICE, Maggie becomes more cooperative and forthcoming with details. If the candidate is dismissive, uses jargon without explanation, or rushes through questions without acknowledging her distress, she becomes withdrawn, gives shorter answers, and may become tearful and stop elaborating. Family cardiac history is hidden — only reveal if the candidate asks specifically about heart disease in close relatives.

Disclose only if asked:

Pain: spreads slightly into left arm and jaw if asked about radiation; started at rest watching TV, no exertional trigger; doesn't ease with rest; 7/10 severity; first time this severe but had milder episodes climbing stairs over the last 2 weeks.
PMH: hypertension (ramipril — sometimes forgets to take it); high cholesterol (atorvastatin); menopause age 52, no HRT; no diabetes; no prior heart problems, clots, or strokes.
Social/smoking: ex-smoker, 20 cigarettes per day for 30 years, stopped 2 years ago; BMI approximately 28; retired teacher, lives with husband, no recent long-haul travel or surgery.
Family history (only disclose if asked specifically): mother died of MI age 58; father had CABG age 60.
Medications: ramipril 5 mg OD, atorvastatin 40 mg ON; no OCP or HRT; no allergies known.
ICE: deeply worried this is a heart attack like her mum — reveal only if candidate asks what she is worried about or what she thinks is causing the pain.

Finish your timed attempt before revealing the answer.

The tasks & expected progression

Take a focused history of the presenting complaint using a structured approach.
Elicit relevant cardiovascular and thrombotic risk factors for this presentation.
Explore Maggie's ideas, concerns, and expectations regarding her symptoms.
Summarise your findings and explain your differential and immediate investigation plan in jargon-free language.
Safety net Maggie with clear instructions on warning features that require urgent re-attendance.

0-1 min Open & rapport Introduce yourself by name and grade. Confirm the patient's name and date of birth. Set the agenda briefly ('I'd like to hear all about what's brought you in today — please tell me in your own words'). Allow an uninterrupted golden minute for the patient to describe her complaint. Use open body language and attentive silence.
1-3 min Explore presenting complaint Explore the pain using SOCRATES: Site (central/retrosternal), Onset (sudden vs gradual, at rest vs on exertion), Character (heavy/pressure vs tearing vs sharp/pleuritic), Radiation (jaw, left arm, back), Associated symptoms (diaphoresis, nausea, vomiting, dyspnoea, palpitations, syncope, haemoptysis, cough, fever, leg swelling). Timing (constant vs intermittent, duration, prior similar episodes). Exacerbating and relieving factors (rest, GTN, posture, deep inspiration). Severity (0-10 NRS).
3-5 min Systematic history & ICE Elicit cardiovascular risk factors: smoking history (pack-years, cessation), hypertension (medications, compliance), hypercholesterolaemia, diabetes, family history of premature coronary disease or MI (especially 1st-degree relatives under 60), prior ACS, PCI, CABG, or PVD, stroke/TIA. Thrombotic risk factors for PE: recent immobility, surgery, long-haul travel, OCP/HRT, malignancy, personal or family VTE history. Aortic risk: connective tissue disease, known aortic disease. Full drug history and allergies. Social history (occupation, support at home). Menopausal status. Elicit ICE: 'Is there anything in particular you're worried this could be?'
5-7 min Red flags & summary Screen targeted red flags: radiation to the back (dissection), haemodynamic instability symptoms (presyncope, syncope), pleuritic component and recent immobility (PE), fever and cough (pneumonia/pericarditis), prior similar episodes and their outcome. Summarise history back to Maggie in plain language. Check she agrees with your summary and invite any corrections or additions.
7-8 min Plan & safety net Explain the differential in plain terms — e.g. 'We need to rule out a problem with the heart, a clot on the lungs, and a few other causes — that's why we'll do blood tests and more heart tracings.' Outline planned investigations (serial ECGs, troponin at 0 and 3 h, chest X-ray, bloods). Safety net: advise Maggie to alert nursing staff immediately if pain worsens, she feels faint, has increasing breathlessness, or develops palpitations. Close by addressing her concern directly and offering to update her husband.

Mark scheme

History

50%

Excellent Elicits a complete SOCRATES pain history including character, radiation to jaw and left arm, onset at rest, autonomic features, and severity score. Asks specifically about prior similar episodes over the preceding 2 weeks. Covers all three life-threatening differentials through targeted questions: tearing radiation to back, pleuritic component, recent immobility. Elicits full cardiovascular risk factor profile including pack-year smoking history, medication compliance, menopausal status, and first-degree family history of premature MI. Completes drug history and allergy screen. No clinically important omissions.
Above standard Elicits SOCRATES comprehensively with minor gaps (e.g. omits severity score or timing of prior episodes). Asks targeted questions for at least two of the three dangerous differentials. Covers most cardiovascular risk factors including smoking cessation, hypertension medications, and family history. Drug history and social history collected. One or two minor risk factors missed but overall history clinically sufficient for risk stratification.
Standard Covers the main features of SOCRATES (site, onset, character, radiation, associated symptoms) but with some gaps, for example misses prior episodes on stairs or forgets to ask about exacerbating factors. Asks about ACS risk factors adequately but explores PE or dissection discriminators only superficially. Family history elicited at a basic level. Drug history obtained. History is sufficient for a working differential but lacks depth in two or three areas.
Borderline Obtains a basic pain history (site, character, onset) but several SOCRATES components are omitted or not followed up. Focuses primarily on ACS history and does not ask any questions directed at PE or aortic dissection. Risk factor screen is incomplete: misses smoking history, medication compliance, or family history. Drug history is cursory. History alone would not support safe differential construction without significant gaps.
Below standard Obtains only a brief or disorganised pain history — for example records chest pain present for 90 minutes without exploring character, radiation, associated symptoms, or prior episodes. Does not systematically screen cardiovascular or thrombotic risk factors. No questions directed at PE or dissection differentials. Drug history and allergy screen absent or incomplete. History is insufficient to support safe management decisions.
Unacceptable Fails to take a structured history of the presenting complaint. Does not explore pain characteristics beyond site or asks only one or two unrelated questions. No risk factor elicitation attempted. Does not ask about medications or allergies. History obtained is wholly insufficient to begin clinical decision-making and represents a patient safety concern.

Communication

30%

Excellent Introduces self by name and grade; confirms patient identity. Provides an uninterrupted golden minute using an open question such as 'Please tell me in your own words what's been happening.' Explicitly elicits ICE with phrasing such as 'Is there something in particular you're worried this could be?' Acknowledges and validates the patient's fear about heart attack with empathetic language ('I can see how frightening this must be, especially given what happened to your mum'). Uses exclusively jargon-free language throughout. Signposts each topic change. Checks understanding before closing.
Above standard Introduces self and confirms identity. Allows an adequate open narrative period, though may redirect slightly early. Elicits ICE and acknowledges the patient's concern with empathy, though the response to the disclosed family history fear is brief rather than fully explored. Explanation of differential and next steps is largely jargon-free with one or two unchecked technical terms. Overall rapport is warm and the patient remains engaged throughout.
Standard Introduces self and sets a basic agenda. History is taken in a predominantly closed-question style with limited opportunity for the patient to provide a narrative. ICE is elicited, though the patient's expressed concern about her mother's MI is acknowledged only briefly without further exploration. Explanation of plan is understandable but contains some medical terminology not explained to the patient. Rapport maintained adequately.
Borderline Introduction is present but brief. History is conducted entirely with closed questions from the outset, allowing no patient narrative. ICE is addressed only after direct prompting by the examiner or not fully explored — the patient's fear about heart attack is not acknowledged or is dismissed with false reassurance. Explanation of next steps contains jargon that is not clarified. Patient appears less engaged by the end of the encounter.
Below standard No clear introduction or role clarification. Consultation is task-focused and empathy is absent — the candidate does not acknowledge the patient's visible anxiety or family history concern. ICE is not elicited at any point. Explanation of investigations and plan uses medical jargon (e.g. 'troponin', 'STEMI', 'Wells score') without explanation. Patient is left more anxious than at the start of the encounter.
Unacceptable Fails to introduce self or confirm patient identity. Consultation is disorganised and the patient's distress is ignored or met with dismissal. ICE is entirely absent. Plan is communicated in technical language the patient cannot understand, or no plan is communicated at all. Communication is harmful to the therapeutic relationship and would be unsafe in clinical practice.

Clinical reasoning

20%

Excellent Presents a prioritised differential that explicitly includes ACS as most likely, aortic dissection, and PE as dangerous alternatives, with brief justification from history findings (e.g. left arm radiation and diaphoresis for ACS; onset at rest and prior episodes for unstable pattern; no pleuritic component or immobility reducing but not excluding PE). Proposes appropriate immediate workup: serial ECGs, high-sensitivity troponin at 0 and 3 hours, chest X-ray, FBC, U&E, coagulation, D-dimer rationale explained. Safety net is explicit and includes specific warning features.
Above standard Identifies ACS and at least one other dangerous differential (PE or dissection) with reasoning linked to history findings. Proposes appropriate investigations including troponin and ECG. Safety net is present and covers at least two warning features. Minor omission in either differential justification or investigation rationale but overall reasoning is clinically sound.
Standard Identifies ACS as the primary differential and mentions one other dangerous cause without detailed reasoning. Investigation plan includes ECG and blood tests but may not explicitly mention serial troponin timing or D-dimer rationale. Safety net is provided but is generic rather than tailored to this patient's specific warning features.
Borderline Identifies ACS only as the working diagnosis without considering alternative dangerous differentials. Investigation plan is incomplete — for example mentions bloods without specifying troponin, or proposes investigations without a clear rationale. Safety net is absent or limited to 'come back if worse' without specifying symptoms. Clinical reasoning is present but insufficient to guide safe workup and disposition.
Below standard Unable to articulate a clear differential diagnosis when prompted. Investigation plan is absent or contains significant errors — for example proposing discharge without investigation or failing to mention any cardiac investigation. Safety net is not provided. Clinical reasoning does not meet the standard expected of an ST4 and would represent an unsafe management plan.
Unacceptable No differential is offered or the differential is non-dangerous and inconsistent with the clinical presentation (e.g. considers only musculoskeletal cause). No investigation plan proposed. No safety net given. Clinical reasoning is absent or actively harmful — for example suggesting the patient can go home without any investigation — and constitutes a patient safety failure.

— Self-mark each domain

Weighted across all domains · Day-1 consultant standard · pass mark 60%.

What good looks like

Women presenting with ACS more often describe atypical features (nausea, fatigue, jaw pain) rather than classic crushing chest pain — avoid anchoring to the classic male presentation.
Family history of premature MI (1st-degree relative under 60) is high-yield for ACS risk and often only disclosed if directly and specifically asked.
Explore all three dangerous differentials through focused history questions: tearing pain radiating to the back (dissection), pleuritic component and immobility (PE), and pressure radiation to jaw/arm with autonomic features (ACS).
ICE elicitation ('Is there anything you're particularly worried this could be?') unlocks the hidden concern about heart attack, facilitates trust, and guides jargon-free explanation.

Common pitfalls

Anchoring on ACS and failing to ask any PE or dissection discriminating questions — missing red flags for the two other life-threatening differentials.
Omitting ICE — the patient's dominant concern (repeating her mother's fatal MI) is not volunteered and must be actively and empathetically elicited.
Using medical jargon (troponin, STEMI, Wells score) without explanation causes the patient to disengage and undermines communication marking.
Failing to safety net explicitly — not telling Maggie what symptoms should prompt her to call for help while awaiting results leaves a patient safety gap.