1. Chest pain
Read the station brief carefully before entering the room. Take a focused history from the patient, interpret the results when provided, and formulate a management plan. You have 8 minutes in total -- use your time efficiently and prioritise clinically significant findings.
Learning points and differential overview
This station tests the candidate's ability to take a structured, focused history from a patient presenting with acute chest pain, recognise features that differentiate aortic dissection from acute coronary syndrome, and communicate an appropriate management plan with clear safety netting. The candidate is expected to demonstrate systematic assessment, red flag recognition, and safe clinical reasoning at registrar level.
Key learning points
- Aortic dissection classically presents with sudden-onset, severe, tearing or ripping chest pain that may radiate to the back or between the shoulder blades, and must be actively excluded before thrombolysis or anticoagulation.
- A blood pressure differential of more than 20 mmHg between arms is a significant clinical sign of aortic dissection and should be actively sought.
- The Stanford classification divides aortic dissection into Type A (involving the ascending aorta, requiring emergency surgery) and Type B (descending only, managed medically unless complicated).
- Risk factors for aortic dissection include hypertension, Marfan syndrome, bicuspid aortic valve, coarctation of the aorta, previous cardiac surgery, and cocaine use.
- The D-dimer has a high sensitivity for ruling out aortic dissection in low-risk patients when used alongside clinical risk stratification tools such as the ADD-RS.
- CT aortography is the definitive imaging investigation for suspected aortic dissection and provides information on extent, involvement of branch vessels, and complications.
- The ECG may be normal, show non-specific changes, or in Type A dissection involving the right coronary ostium, may mimic an inferior STEMI -- treating a dissection with thrombolytics can be fatal.
- Immediate management of suspected aortic dissection includes IV access, analgesia, blood pressure control (target systolic 100--120 mmHg), senior review, cardiothoracic surgical referral, and group and save.
- A thorough pain history using SOCRATES is essential in differentiating the major causes of acute chest pain including ACS, aortic dissection, pulmonary embolism, pericarditis, and oesophageal causes.
- Clear safety netting and early senior involvement are critical when aortic dissection is on the differential, as this is a time-critical, life-threatening emergency.
Key differentials to consider
- Aortic dissection (Type A or B)
- Acute coronary syndrome (NSTEMI or STEMI)
- Pulmonary embolism
- Acute pericarditis
- Hypertensive emergency
- Oesophageal rupture (Boerhaave syndrome)
- Musculoskeletal chest pain
- Pneumothorax
Station instructions
Marcus Bailey is a 58-year-old man who has been brought to the emergency department by ambulance after developing sudden-onset severe chest pain at rest approximately one hour ago. He describes the pain as the worst he has ever felt. Observations on arrival are: heart rate 102 beats per minute, blood pressure 162/94 mmHg in the right arm (left arm not yet recorded), respiratory rate 22 breaths per minute, oxygen saturation 96% on air, and temperature 36.8 degrees Celsius. He is pale, diaphoretic, and visibly distressed. You are the emergency medicine registrar. Please take a focused history from Mr Bailey, interpret the investigations when provided by the examiner, and explain your working diagnosis and immediate management plan to the patient. You have 8 minutes.
Introduction and Initial Assessment
Dr Reza Tehrani: Hello Mr Bailey, I am Dr Reza Tehrani, one of the emergency medicine registrars. I can see you are in a lot of discomfort right now -- I am going to do my best to help you. Is it alright if I ask you some questions while we get things sorted?
Dr Reza Tehrani: I absolutely will. Before we go any further, on a scale of zero to ten, how bad is the pain right now?
Dr Reza Tehrani: I am going to make sure we get you some pain relief very shortly. Can you point to exactly where the pain is?
Character and Onset of Pain
Dr Reza Tehrani: Can you describe what the pain actually feels like -- is it a pressure, a squeezing, a burning, or something else?
Dr Reza Tehrani: That is a really important detail, thank you. When exactly did it start, and did it come on suddenly or build up gradually?
Dr Reza Tehrani: Has the pain moved anywhere else, for example into your jaw, your arm, or your legs?
Dr Reza Tehrani: Has the pain changed at all since it started -- better, worse, or stayed the same?
Associated Symptoms and Red Flags
Dr Reza Tehrani: Have you noticed any shortness of breath, dizziness, or feeling like you might faint?
Dr Reza Tehrani: Have you noticed any weakness or change in sensation in your arms or legs, any difficulty speaking, or any changes in your vision?
Dr Reza Tehrani: Have you had any episodes of vomiting, coughing up blood, or noticed any blood in your urine or stool?
Dr Reza Tehrani: Did anything bring the pain on -- physical exertion, emotional stress, or did it truly come from nowhere at rest?
Risk Factors and Background History
Dr Reza Tehrani: Has anything like this ever happened to you before?
Dr Reza Tehrani: Do you have any medical conditions that you have been diagnosed with -- for example high blood pressure, diabetes, high cholesterol, or any heart conditions?
Dr Reza Tehrani: Are there any conditions that run in your family -- in particular any heart problems, or anyone who has had problems with the aorta or major blood vessels?
Dr Reza Tehrani: What medications do you take, and do you have any allergies?
Dr Reza Tehrani: Do you smoke, drink alcohol, or use any recreational drugs including cocaine?
Ideas, Concerns and Expectations
Dr Reza Tehrani: I can imagine this has been terrifying. What have you been thinking might be causing this pain?
Dr Reza Tehrani: That is a very understandable worry and it is one of the things we absolutely need to rule out. Is there anything specific you are particularly worried about right now?
Dr Reza Tehrani: I completely understand, and I promise we will get to the bottom of this as quickly as possible. Is there anything in particular you are hoping we can do for you today?
Results (for candidates who ask)
Click to reveal ECG
ECG report: Sinus tachycardia at 104 beats per minute. Normal axis. No ST elevation. No pathological Q waves. Mild ST depression of 1 mm in leads V4 to V6. No left bundle branch block. No features of pericarditis. No right heart strain pattern.
Click to reveal blood results
• WBC 11.2 x10^9/L (mildly elevated)
• Platelets 228 x10^9/L (normal)
• Sodium 138 mmol/L (normal)
• Potassium 4.1 mmol/L (normal)
• Urea 6.8 mmol/L (normal)
• Creatinine 94 umol/L (normal)
• Troponin I (high sensitivity) 28 ng/L at 0 hours (upper limit of normal 34 ng/L -- borderline)
• D-dimer 3,840 ng/mL (significantly elevated)
• CRP 8 mg/L (mildly elevated)
• Glucose 7.2 mmol/L (mildly elevated)
• Lactate 2.1 mmol/L (mildly elevated)
• Group and save -- sent
Chest X-ray: Widened mediastinum measuring approximately 9 cm at the level of the aortic knuckle. Mild cardiomegaly. No pneumothorax. No pulmonary oedema. No pleural effusion. The aortic knuckle contour is irregular.
Explaining diagnosis and ED plan
Dr Reza Tehrani: Mr Bailey, thank you for bearing with me. I have now had a chance to review your ECG, your blood tests, and your chest X-ray, and I want to explain what we have found and what we think might be happening.
Dr Reza Tehrani: Your heart tracing -- the ECG -- shows your heart is beating a little fast, which makes sense given the pain you are in. There are some minor changes but there is no sign of a straightforward heart attack on the ECG. Your heart marker in the blood -- called troponin -- is at the upper limit of normal, which means we cannot be certain about your heart yet, but there is something else that is concerning us more urgently.
Dr Reza Tehrani: Your chest X-ray shows that the large blood vessel that comes out of your heart -- called the aorta -- appears wider than it should be. Combined with the way the pain came on suddenly, the tearing quality you described, and the fact it went through to your back, we are very concerned about a condition called aortic dissection. This is where the inner lining of that large vessel tears away.
Dr Reza Tehrani: I will be honest with you -- this is a serious condition that we need to investigate and treat urgently, and I do not want to minimise that. However, you are in the right place, and we are taking action right now. The next step is a special type of CT scan called a CT aortogram, which will give us a detailed picture of the aorta and tell us exactly what is happening.
Dr Reza Tehrani: That depends on where exactly the tear is. If it involves the part of the aorta closest to the heart, it usually requires emergency surgery. If it is in a different part, it can often be managed with medicines to control your blood pressure very carefully. I am going to involve our senior consultant right now, and we will also be speaking to the specialist surgeons.
Dr Reza Tehrani: Absolutely, I will make sure your wife is brought in to be with you as soon as possible. While we are waiting for the scan, we are going to give you strong pain relief through the drip, carefully lower your blood pressure with some medication, and keep a very close eye on your observations. We also need to check the blood pressure in both of your arms -- I would like to do that now.
Dr Reza Tehrani: I absolutely will keep you informed at every step. You are in safe hands, and the whole team is working on this together. Do you have any questions before I go and organise everything?
Dr Reza Tehrani: I hear you, Mr Bailey. We are doing everything we can, and we will not stop working for you. I will be back very shortly.
Self assessment and examiner scoring
Select 0, 1 or 2 for each item and click Calculate. Total is out of 20.
Examiner checklist (reference)
- Candidate introduced themselves by name and role and established rapport with a distressed patient
- Candidate used a structured approach to the pain history covering onset, character, radiation, severity, timing, and associated features
- Candidate specifically identified the sudden onset, tearing quality, and posterior radiation as red flags for aortic dissection
- Candidate asked about neurological symptoms, syncope, and limb weakness suggesting involvement of branch vessels
- Candidate elicited a relevant past medical, family, drug, and social history including poorly controlled hypertension and family history of aortic or cardiac events
- Candidate correctly identified the widened mediastinum on chest X-ray as a key finding consistent with aortic dissection
- Candidate recognised the limitation of the borderline troponin and did not anchor on ACS as the sole diagnosis
- Candidate proposed CT aortogram as the definitive investigation and mentioned bilateral blood pressure measurement
- Candidate communicated the working diagnosis sensitively, using accessible language, and addressed the patient's fear and concerns
- Candidate escalated appropriately to senior and cardiothoracic surgical colleagues and outlined immediate management including analgesia and blood pressure control
Actor brief
Patient name: Marcus Bailey
Age: 58 years
Background: You are Marcus Bailey, a 58-year-old man who works as a school caretaker. You live with your wife and have two adult children and three grandchildren. You have had high blood pressure for many years and your GP has repeatedly told you it is not well managed. You take your tablets inconsistently because you feel well most of the time. You are generally stoic and not prone to visiting the doctor, but tonight's pain was so severe it terrified you.
Opening line: Please, you have to help me -- I have never felt pain like this in my life.
Presenting illness: You were sitting at home watching football one hour ago when you suddenly experienced an explosive, severe, tearing pain in the centre of your chest. It immediately radiated through to your back, between your shoulder blades. The pain has not eased at all. It is constant and feels like something is being ripped apart inside you. You also felt dizzy and nearly fainted when you stood up to call the ambulance. You have noticed some numbness and weakness in your left arm since the pain started but you have not focused on this much.
Red flag negatives: No haemoptysis. No haematemesis. No rectal bleeding. No preceding exertion. No fever. No recent long-haul travel. No leg swelling or calf pain. No recent surgery or illness.
Past medical history: Hypertension for 15 years -- poorly controlled. Hypercholesterolaemia. No prior cardiac events, no previous surgery, no known connective tissue disorder.
Drug history: Amlodipine 10 mg once daily. Atorvastatin 40 mg once daily. No over-the-counter medications. No known drug allergies.
Social history: Ex-smoker -- 20 pack years, stopped 8 years ago. Drinks approximately 15 units of alcohol per week. No recreational drug use. Works as a school caretaker. Married. Lives in a house with stairs.
Family history: Father died aged 61 -- cause not entirely clear, possibly related to the heart or a large blood vessel. Elder brother has a heart condition -- details not known.
Ideas: You initially assumed it was a heart attack. You have heard of heart attacks and this seemed to fit. You are not aware of aortic dissection as a condition.
Concerns: You are terrified of dying suddenly like your father. You are desperate to be there for your grandchildren. You are scared about the possibility of surgery.
Expectations: You want the pain to be treated urgently. You want to know what is wrong with you in clear terms. You want your wife to be allowed in with you.
Behaviour during station: You are visibly distressed and pale. You are cooperative but anxious and frightened. You may become emotional when talking about your grandchildren or your father. You are not aggressive. If the doctor is calm and clear, you will respond well and become slightly more settled. If asked about the left arm weakness, you confirm it -- you had not volunteered it because you were focused on the chest and back pain.
Information to give only if asked directly:
- If asked about the character of the pain: it is tearing or ripping, not squeezing or burning
- If asked about radiation: it went straight through to the back, between the shoulder blades
- If asked about onset: it was instantaneous, at rest, with no warning
- If asked about left arm: there is definite numbness and some weakness -- you had not mentioned it spontaneously
- If asked about near-syncope: yes, you nearly passed out when you stood up to get the phone
- If asked about blood pressure control: you admit you often forget your tablets and have not had a GP review in over a year
- If asked about Marfan features or tall stature: you are 6 feet tall and have always had long fingers -- a doctor once mentioned you were quite tall and slender for your build
- If asked about cocaine use: firmly deny any recreational drug use
- If asked about previous similar episodes: never had anything like this before
Emotional mark points: You should appear genuinely frightened throughout. When the doctor mentions the possibility of surgery or that the condition is serious, you should show visible distress and may become tearful briefly, especially when mentioning your grandchildren. If the doctor is empathetic and explains things clearly, you should visibly settle a little and express gratitude.
