Registrar-level OSCE preparation that mirrors the real exam.

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

1. Candidate introduced themselves by name and role and established rapport with a distressed patient
2. Candidate used a structured approach to the pain history covering onset, character, radiation, severity, timing, and associated features
3. Candidate specifically identified the sudden onset, tearing quality, and posterior radiation as red flags for aortic dissection
4. Candidate asked about neurological symptoms, syncope, and limb weakness suggesting involvement of branch vessels
5. Candidate elicited a relevant past medical, family, drug, and social history including poorly controlled hypertension and family history of aortic or cardiac events
6. Candidate correctly identified the widened mediastinum on chest X-ray as a key finding consistent with aortic dissection
7. Candidate recognised the limitation of the borderline troponin and did not anchor on ACS as the sole diagnosis
8. Candidate proposed CT aortogram as the definitive investigation and mentioned bilateral blood pressure measurement
9. Candidate communicated the working diagnosis sensitively, using accessible language, and addressed the patient's fear and concerns
10. Candidate escalated appropriately to senior and cardiothoracic surgical colleagues and outlined immediate management including analgesia and blood pressure control

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.