History Taking · Foundation · Cardiovascular

Chest Pain in a 58 year old man

Practise this PLAB 2 history taking station on Unstable Angina. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr James Thornton, a 58-year-old man, has come to see you with chest pain that started three days ago. He appears uncomfortable and slightly anxious. Please take a focused history and discuss your initial management plan with the patient.

Background notes: PMH: Hypertension, Hypercholesterolaemia, T2DM, Knee arthroscopy

What this station tests

  • Systematic cardiac history using SOCRATES, actively asking about radiation (patient will not volunteer jaw and arm involvement)
  • Red flag screening: distinguishing unstable angina from ACS, PE, aortic dissection, and musculoskeletal causes
  • Cardiovascular risk factor assessment: linking PMH (hypertension, diabetes, hypercholesterolaemia), family history, and lifestyle
  • Exploring ICE: uncovering Mr Thornton's fear about cardiac disease (father and brother) beneath his surface attribution to indigestion
  • Immediate management planning: aspirin 300mg stat, ECG, troponin, and appropriate referral pathway

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

In any chest pain history taking station, the first 60 seconds should establish rapport and let the patient describe their symptoms without interruption. Introduce yourself, confirm identity, and open with: 'What's brought you in today?' In this case, Mr Thornton appears uncomfortable and slightly anxious. Acknowledge this early: 'I can see you look a bit uncomfortable, are you in any pain right now?' He will describe chest pain but downplay it. He attributes the pain to indigestion or a pulled muscle. His wife insisted he come. Let him talk and note what he volunteers versus what he withholds.

Core approach

For cardiac chest pain, SOCRATES must actively elicit features the patient will not volunteer. Mr Thornton's pain is central, heavy, and pressing ('like someone sitting on my chest'), brought on by exertion (stairs, walking uphill, carrying things), and relieved by rest within 5 to 10 minutes. The critical finding is radiation to his left arm and jaw, but he will only reveal this if you specifically ask 'Does the pain go anywhere else?' Do not wait for him to offer it. His worst episode lasted 15 minutes yesterday walking uphill, suggesting a crescendo pattern consistent with unstable angina. Antacids made no difference, which challenges his indigestion theory.

Screen for red flags: he felt sweaty and nauseated during the worst episode. No syncope, no calf pain, no pleuritic or positional features. Pain is not reproducible on palpation, which helps exclude musculoskeletal causes.

Cardiovascular risk assessment is where many candidates score or lose marks. Mr Thornton has hypertension, hypercholesterolaemia, and type 2 diabetes. He is on amlodipine, atorvastatin 20mg (subtherapeutic for ACS risk), and metformin, with occasional ibuprofen. He misses 2 to 3 doses monthly. Family history must be actively asked: his father had an MI at 62, his brother had a stent at 59. This is strong first-degree premature coronary disease. Social history: ex-smoker (20/day for 20 years, quit 8 years ago), alcohol 20 to 25 units weekly, poor diet, no exercise, high occupational stress.

Explore ICE. His Idea is indigestion, but underneath he fears cardiac disease because of his father and brother. His main Concern is what a cardiac diagnosis means for his driving and his job as a sales manager. His wife was in tears this morning. If you do not ask, you will not discover any of this.

Closing and safety netting

In any suspected ACS station, the closing must include a clear differential, immediate actions, and specific safety netting. Summarise findings back to Mr Thornton in plain language: the pattern of pain, his risk factors, and family history all point toward unstable angina. Explain the plan: ECG today, blood tests including troponin, and depending on results, same-day referral to a chest pain assessment unit. Give aspirin 300mg to chew now. Address his driving concern: DVLA notification is required after an ACS diagnosis. Safety net specifically: 'If the pain returns and lasts more than 15 minutes, or you feel breathless and sweaty, call 999 and chew an aspirin while you wait.' He may say 'I was afraid you'd say that.' Respond with empathy: the important thing is catching this now.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for unstable angina. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Systematic SOCRATES history that actively elicits radiation to arm and jaw. Screening for red flags (diaphoresis, nausea, syncope). Thorough cardiovascular risk factor inventory: PMH of hypertension, diabetes, hypercholesterolaemia; family history of premature MI in father and brother; lifestyle factors including smoking history, alcohol, sedentary lifestyle.

Costs marks: Accepting the indigestion attribution without probing. Missing the radiation to arm and jaw (only revealed on direct questioning). Not asking family history. Incomplete medication history (missing the subtherapeutic atorvastatin dose and ibuprofen use).

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Clear differential communicated to the patient: unstable angina as working diagnosis, with MI and stable angina as differentials. Immediate plan: aspirin 300mg, ECG, troponin, referral pathway. Specific safety netting: 'call 999 if pain lasts more than 15 minutes or you feel sweaty and unwell.' DVLA driving advice.

Costs marks: Vague management ('we will do some tests'). No aspirin given. No specific safety netting. Not mentioning DVLA restrictions. Failing to address the inadequate atorvastatin dose.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging Mr Thornton's discomfort at the start. Letting him describe symptoms in his own words before directing. Exploring his fear about cardiac disease (father and brother). Addressing the occupational and family impact (wife in tears, job depends on driving). Empathic response when he says 'I was afraid you'd say that.'

Costs marks: Interrupting his narrative. Ignoring his initial attribution without exploring why he thinks that. Not addressing his wife's anxiety. Using technical language ('NSTEMI', 'troponin') without explanation. Dismissing his concern about driving and work.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Accepting Mr Thornton's attribution of pain to 'indigestion or a pulled muscle' without challenge. The actor will not volunteer radiation to the arm and jaw unless specifically asked. Candidates who do not ask 'Does the pain go anywhere else?' miss the most important discriminating feature of cardiac chest pain.
  2. Failing to ask about family history. Mr Thornton's father had an MI at 62 and his brother had a stent at 59. This first-degree family history of premature coronary disease significantly changes the clinical picture, but the actor will not mention it unless directly asked.
  3. Not addressing the occupational impact. Mr Thornton is a regional sales manager who drives long distances. DVLA notification is required after an ACS diagnosis, and this directly threatens his livelihood. Candidates who ignore this concern miss an important Domain 3 opportunity and leave the patient with unaddressed anxiety.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take an unstable angina history in PLAB 2?

In any chest pain history taking station, the first 60 seconds should establish rapport and let the patient describe their symptoms without interruption. Introduce yourself, confirm identity, and open with: 'What's brought you in today?' In this case, Mr Thornton appears uncomfortable and slightly anxious. Acknowledge this early: 'I can see you look a bit uncomfortable, are you in any pain right now?' He will describe chest pain but downplay it.

Where are marks won and lost in this unstable angina station?

Examiners reward: Systematic SOCRATES history that actively elicits radiation to arm and jaw. Screening for red flags (diaphoresis, nausea, syncope). Candidates are penalised for: Accepting the indigestion attribution without probing. Missing the radiation to arm and jaw (only revealed on direct questioning).

Where do candidates most often go wrong in this station?

Accepting Mr Thornton's attribution of pain to 'indigestion or a pulled muscle' without challenge. The actor will not volunteer radiation to the arm and jaw unless specifically asked. Candidates who do not ask 'Does the pain go anywhere else?' miss the most important discriminating feature of cardiac chest pain.

Can I do well in this station without real-world experience of unstable angina?

Structure beats experience here. Focus on red flag screening: distinguishing unstable angina from ACS, PE, aortic dissection, and musculoskeletal causes. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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