Cardiology 8 Minutes Arthur Mitchell, 58 yo (Emergency Department)

Acute Retrosternal Chest Pain History

Candidate Instructions: Arthur Mitchell, 58, presents to the Emergency Department with sudden-onset chest pain. Please take a focused history, identify critical red flags, assess cardiovascular risk factors, and formulate a management plan.

Examiner Marking Checklist

History of Presenting Complaint (SOCRATES)

✓ Site: Retrosternal / central chest
✓ Onset: Sudden, started 90 minutes ago at rest
✓ Character: Heavy, crushing, tight band
✓ Radiation: Radiates to left jaw and inner left arm
✓ Associated: Sweating, nausea, mild dyspnoea
✓ Timing: Constant, no relief with paracetamol
✓ Exacerbating/Relieving: Worse on exertion, rest gives no relief
✓ Severity: 8/10

Past Medical & Risk Factors

✓ Cardiovascular risk screen: Hypertension, hyperlipidaemia, diabetes
✓ Smoking history: 25 pack-years
✓ Family history: Father had myocardial infarction at age 52
✓ Drug history: Amlodipine 5mg, checks for allergy

Communication & Empathy

✓ Acknowledge pain and distress promptly
✓ Offer immediate analgesia / oxygen reassurance
✓ Maintain eye contact and active listening

Critical Red Flags

⚠ Haemodynamic instability (hypotension, bradycardia/tachycardia)
⚠ Tearing interscapular back pain (Aortic Dissection)
⚠ Unilateral leg swelling with sudden pleurisy (Pulmonary Embolism)

Post-Station Examiner Questions

Examiner: "What immediate bedside investigations would you request within 10 minutes?"

Model Answer: 12-lead ECG, continuous cardiac monitoring, high-sensitivity troponin, bedside point-of-care capillary blood glucose, and portable chest X-ray.

Examiner: "What initial pharmacotherapy would you administer for suspected STEMI/NSTEMI?"

Model Answer: Aspirin 300mg chewed, sublingual GTN (if SBP > 90mmHg), adequate opioid analgesia with antiemetic, and ticagrelor/clopidogrel based on local STEMI/PCI pathways.

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