Chest Pain in the Emergency Department (OSCE focused) ❤️

Candidate Instructions: You are the medical student in A&E. A 58-year-old man presents with central chest pain. Take a focused history to determine the likely cause. Do not examine or manage at this stage.

Key Areas to Cover ✅

• SOCRATES pain history (site, onset, character, radiation, associated, timing, exacerbating/relieving, severity).
• Associated features: dyspnoea, diaphoresis, palpitations, nausea, syncope.
• Risk factors: hypertension, smoking, diabetes, hyperlipidaemia, family history of IHD.
• Past history: previous angina/MI, PCI, CABG.
• Drug history: nitrates, aspirin, anticoagulants.
• Red flags: tearing back pain (aortic dissection), pleuritic pain (PE, pneumothorax).

Examiner Prompts 💬

• “How would you differentiate cardiac from non-cardiac chest pain?”
• “What are the immediate investigations you’d request?”

Differential Diagnoses 🔎

• ACS (STEMI/NSTEMI/unstable angina)
• Musculoskeletal chest pain
• PE / pneumothorax / pneumonia
• Aortic dissection
• GORD/oesophageal spasm

Mark Scheme (10 points) 📝

Teaching Commentary 📚

In OSCEs, you’ll score highly if you structure the chest pain history clearly with SOCRATES. Remember to ask about red flag differentials (tearing pain → aortic dissection; pleuritic pain → PE/pneumothorax). Risk factor exploration is a must in UK exams. Always end by acknowledging patient anxiety - chest pain is frightening!

🧑‍⚕️ Case Examples - Chest Pain in the Emergency Department

• Case 1 (ST-Elevation Myocardial Infarction): ❤️‍🔥 A 60-year-old man with hypertension presents with crushing central chest pain radiating to the left arm, associated with sweating and nausea. ECG shows ST elevation in leads II, III, aVF. Troponin elevated. Diagnosis: Inferior STEMI. Teaching point: Classic ACS; reperfusion therapy with PCI (or thrombolysis if PCI not available).
• Case 2 (Pulmonary Embolism): 🫁 A 45-year-old woman on the pill presents with sudden pleuritic chest pain, dyspnoea, and haemoptysis. She is tachycardic and hypoxic. CTPA confirms segmental PE. Diagnosis: Pulmonary embolism. Teaching point: Always consider PE in acute chest pain with SOB; risk stratify (Wells, PESI) and start anticoagulation promptly.
• Case 3 (Aortic Dissection): ⚡ A 68-year-old man with poorly controlled hypertension reports tearing chest pain radiating to the back. BP 190/110 mmHg, radiofemoral delay noted. CT angiogram shows Stanford type B dissection. Diagnosis: Aortic dissection. Teaching point: Tearing pain + pulse deficit = dissection until proven otherwise; manage with BP control (IV labetalol) and surgical review.
• Case 4 (Pericarditis): 🔥 A 35-year-old man presents with sharp central chest pain worse on inspiration and lying flat, relieved by sitting forward. ECG shows widespread ST elevation and PR depression. Diagnosis: Acute pericarditis. Teaching point: Pleuritic, positional chest pain with classic ECG changes = pericarditis; treat with NSAIDs and colchicine if no contraindications.
• Case 5 (Pneumothorax): 🌬️ A 25-year-old tall, thin man develops sudden right-sided chest pain and breathlessness while playing basketball. On exam: reduced breath sounds and hyperresonance on the right. CXR shows a right-sided pneumothorax. Diagnosis: Primary spontaneous pneumothorax. Teaching point: Sudden pleuritic chest pain in young adults = pneumothorax; management depends on size and symptoms (aspiration vs chest drain).
• Case 6 (Stable Angina with Exacerbation): 🚶 A 70-year-old man reports central chest tightness on exertion, relieved by rest within minutes. ECG is normal at rest. Troponins are not elevated. Diagnosis: Stable angina (presentation in ED due to poor control). Teaching point: Always differentiate exertional angina from ACS; long-term management with GTN, beta-blockers, statins, and risk factor control.
• Case 7 (Gastro-Oesophageal Reflux / Oesophagitis): 🌡️ A 40-year-old woman presents with burning retrosternal chest pain after meals and lying flat. Pain improves with antacids. ECG and troponins are normal. Diagnosis: GORD presenting as chest pain. Teaching point: GI causes can mimic cardiac chest pain; red flags (dysphagia, weight loss, anaemia) warrant endoscopy.
• Case 8 (Musculoskeletal Costochondritis): 💪 A 35-year-old man reports sharp, localised chest pain worsened by movement and palpation of the costal cartilage. Vitals, ECG, and troponins are normal. Diagnosis: Costochondritis. Teaching point: MSK chest pain is common in ED; reproducibility on palpation is a key clue.
• Case 9 (Pneumonia with Pleurisy): 🦠 A 58-year-old woman presents with fever, productive cough, and pleuritic chest pain. CXR shows left lower lobe consolidation. Diagnosis: Community-acquired pneumonia. Teaching point: Pleuritic chest pain + fever = think pneumonia or PE; CXR is diagnostic here. Treat with antibiotics per CURB-65 score.
• Case 10 (Oesophageal Rupture - Boerhaave’s Syndrome): 💥 A 50-year-old man develops sudden severe chest pain after repeated vomiting following heavy alcohol intake. Exam shows subcutaneous emphysema. CXR reveals mediastinal air. Diagnosis: Boerhaave’s syndrome (spontaneous oesophageal rupture). Teaching point: Rare but lethal cause of chest pain; requires urgent surgical repair and broad-spectrum antibiotics.