Door prompt
Setting: Emergency department
Patient: Mr. Daniel Karim, 58 years old
Presenting concern: Central chest pressure for 45 minutes.
Your task: Take a focused history, explain your initial impression to the patient, and discuss the immediate next steps. You do not need to perform a physical examination, but you should describe the focused examination you would complete.
Candidate instructions
- Open with introduction, identity confirmation, consent, and brief agenda.
- Prioritize life-threatening causes of chest pain.
- Ask focused OPQRST, associated symptoms, cardiovascular risk factors, medication history, allergies, and contraindications to treatment.
- State immediate safety steps: vitals, cardiac monitoring, IV access, ECG, troponin, and urgent physician/team involvement.
- Communicate clearly and avoid jargon.
Examiner checklist
History taking
- Confirms patient identity and obtains consent.
- Characterizes pain: onset, location, radiation, duration, severity, quality, triggers, relieving factors.
- Asks associated symptoms: dyspnea, diaphoresis, nausea/vomiting, syncope, palpitations.
- Screens for ACS risk: hypertension, dyslipidemia, diabetes, smoking, family history, prior CAD/stroke/PAD.
- Checks medication use, anticoagulants/antiplatelets, erectile dysfunction medications, allergies.
- Considers alternative dangerous diagnoses: PE, aortic dissection, pneumothorax, esophageal rupture.
Assessment and management
- States that ACS/STEMI must be excluded urgently.
- Requests immediate 12-lead ECG and repeat ECGs if symptoms continue.
- Orders cardiac biomarkers, CBC, electrolytes/creatinine, coagulation studies, glucose, chest X-ray when appropriate.
- Initiates cardiac monitoring, IV access, vital signs, and oxygen only if hypoxemic or clinically indicated.
- Discusses aspirin if no contraindication and urgent escalation for reperfusion pathway if STEMI.
- Explains plan clearly and reassures without minimizing risk.
Oral questions
1. What are your top differential diagnoses?
Acute coronary syndrome, pulmonary embolism, aortic dissection, pneumothorax, pericarditis/myocarditis, GERD/esophageal spasm, and musculoskeletal chest pain. ACS should be prioritized because of age, typical pressure-like pain, radiation, diaphoresis/nausea, and cardiovascular risk factors.
2. What immediate investigations are required?
Immediate 12-lead ECG, cardiac biomarkers with serial testing, vital signs, oxygen saturation, CBC, electrolytes/creatinine, glucose, coagulation studies if anticoagulation/procedure likely, and chest X-ray when clinically appropriate. Do not delay reperfusion for troponin if the ECG shows STEMI.
3. What initial management would you start?
Cardiac monitor, IV access, repeat vitals, analgesia as appropriate, aspirin if no contraindication, nitrates if appropriate and not hypotensive/right ventricular infarct/PDE-5 inhibitor use, anticoagulation/dual antiplatelet strategy according to ACS pathway, and urgent cardiology/PCI activation if STEMI.
Scoring feedback
Strong performance
You quickly identify ACS as a time-sensitive diagnosis, ask contraindications before treatment, request ECG immediately, and explain the plan in calm patient-centred language.
Common unsafe omissions
Waiting for troponin before ECG-based STEMI activation, forgetting aortic dissection/PE red flags, giving nitrates without checking hypotension/PDE-5 inhibitor use, or providing reassurance before life-threatening causes are excluded.