History Taking · Intermediate · Cardiovascular

Chest Pain to Pericarditis

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

Clinical scenario

You are an FY2 doctor in the Emergency Department. Miss Sophie Brennan, a 24-year-old woman, has presented with chest pain that started yesterday. She appears anxious and is sitting forward on the trolley. Please take a focused history and discuss your initial management plan with the patient.

Background notes: PMH: Mild asthma (well-controlled, PRN salbutamol), Appendicectomy age 14, Preceding viral URTI 10 days ago

What this station tests

  • Distinguishing pericarditis from ACS and PE in a young woman: positional features (worse lying flat, better sitting forward), pleuritic nature, and sharp character versus the heavy, exertional pain of ACS
  • Actively eliciting the preceding viral illness: the patient will not mention her cold unless asked about recent infections, and this is the key aetiological link
  • Considering PE as a differential: young woman on combined OCP with pleuritic chest pain requires active exclusion of pulmonary embolism
  • Explaining a diagnosis to a frightened, health-literate young patient: clear language, addressing Google-fuelled anxiety, distinguishing 'heart lining' from 'heart attack'
  • Activity restriction counselling: explaining why parkrun and yoga must stop temporarily, with a clear timeline for review

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

When a young patient presents with chest pain, the differential is wide and the candidate's job is to distinguish cardiac from non-cardiac causes through targeted questioning. Miss Brennan is 24, anxious, and sitting forward on the trolley. Notice and comment on her posture: 'I can see you're sitting forward. Is that more comfortable?' This simultaneously builds rapport and gathers clinical data, since sitting forward is a classic pericarditis feature. She is frightened because her boyfriend googled 'chest pain in young woman' and saw heart attack and blood clot. Begin with: 'Tell me what's been happening.'

Core approach

The key discriminators for pericarditis versus ACS are positional variation and pain character. Miss Brennan's pain is sharp and stabbing (not heavy or pressing), central and slightly left-sided, significantly worse lying flat and on deep inspiration, and markedly improved by sitting forward. She discovered the positional relief by accident when leaning to pick up her phone. Radiation is to her back between the shoulder blades (not to the arms or jaw). Paracetamol helped minimally but ibuprofen worked better, which is a useful therapeutic clue for inflammatory pericardial pain.

The history that candidates must actively elicit is the preceding viral illness. She had a nasty cold 10 days ago: sore throat, body aches, fever, three days off work. She will not mention this unless you ask about recent illnesses. This is the most likely trigger for viral pericarditis, and missing it leaves your differential incomplete.

Consider PE in the differential. She takes Microgynon (combined OCP) for five years, which she will only reveal if you ask about medications. A young woman on combined OCP with pleuritic chest pain requires active PE exclusion. However, her pain is positional and bilateral pleuritic, which favours pericarditis over PE.

PMH: mild asthma (PRN salbutamol), appendicectomy at 14, penicillin allergy. No family history of cardiac disease or clots. Non-smoker, active (yoga, parkrun, walks to school). ICE: she fears a heart attack (Tom's googling), worries about a blood clot (she read the pill causes clots), and wants to know if she can still run parkrun this Saturday.

Closing and safety netting

For pericarditis, the closing should provide clear reassurance while explaining what it is and is not. 'Sophie, the most likely explanation is pericarditis, which is inflammation of the lining around your heart. It is not a heart attack.' Pause and let relief register. Link it to her viral illness: 'That cold you had 10 days ago is the most likely trigger.' Investigations: ECG (looking for widespread ST elevation distinct from ACS), bloods (inflammatory markers, troponin), chest X-ray. Treatment: ibuprofen (which she already found helpful) plus colchicine to reduce recurrence risk. She will ask what colchicine is. Explain the exercise restriction: no running, no vigorous yoga until symptoms and bloods normalise. She will be disappointed. Safety net: return if worsening pain, increasing breathlessness, feeling faint (tamponade features). Address the pill question: OCP is not related to pericarditis, separate GP discussion if concerned.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute pericarditis. 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: Complete SOCRATES with active elicitation of positional features (worse lying flat, better sitting forward) and preceding viral illness. Asking about OCP use to consider PE differential. Noting the sitting-forward posture. Asking about autoimmune features and travel history to broaden the differential appropriately.

Costs marks: Not asking about recent illness (missing the viral trigger). Not asking about medications (missing OCP and PE consideration). Incomplete pain characterisation: not exploring positional and respiratory features that distinguish pericarditis from ACS.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Accurate explanation of pericarditis in plain language. Appropriate investigation plan (ECG looking for saddle-shaped ST elevation, bloods including troponin, CXR). Correct treatment: NSAID plus colchicine. Clear activity restriction with review timeline. Appropriate safety netting for tamponade features.

Costs marks: Incorrectly diagnosing ACS or PE without considering pericarditis. Not mentioning colchicine (which halves recurrence risk). Forgetting activity restriction. Vague safety netting that does not mention worsening breathlessness or faintness (tamponade red flags).

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing her Google-fuelled anxiety early and directly. Reassuring her clearly that this is not a heart attack while explaining what it actually is. Responding to her boyfriend Tom's concerns (she will mention his googling). Handling her disappointment about exercise restriction with empathy. Explaining colchicine when she asks 'What is that?'

Costs marks: Dismissing her anxiety ('You're too young for a heart attack'). Not explaining what pericarditis is. Using jargon like 'pericardial friction rub' or 'saddle-shaped ST elevation' without translation. Ignoring her question about whether the pill is safe.

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. Missing the preceding viral illness. Miss Brennan will not mention her cold from 10 days ago unless directly asked about recent infections or illnesses. Without this, the differential remains broad and the most likely aetiology (viral pericarditis) is missed.
  2. Not asking about contraceptive pill use. The medication history reveals she takes Microgynon (combined OCP). In a young woman with pleuritic chest pain, PE must be considered and actively excluded. Candidates who do not take a drug history miss this differential.
  3. Failing to observe and comment on her posture. Miss Brennan is sitting forward on the trolley, a classic pericarditis sign. Candidates who note this and link it to the positional nature of the pain demonstrate strong clinical observation skills.

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

How do I approach the consultation in this acute pericarditis station?

When a young patient presents with chest pain, the differential is wide and the candidate's job is to distinguish cardiac from non-cardiac causes through targeted questioning. Miss Brennan is 24, anxious, and sitting forward on the trolley. Notice and comment on her posture: 'I can see you're sitting forward.

What does a strong performance look like to the examiner in this station?

Strong performances show: Complete SOCRATES with active elicitation of positional features (worse lying flat, better sitting forward) and preceding viral illness. Weak performances: Not asking about recent illness (missing the viral trigger). Not asking about medications (missing OCP and PE consideration).

What is the biggest pitfall in this acute pericarditis station?

Missing the preceding viral illness. Miss Brennan will not mention her cold from 10 days ago unless directly asked about recent infections or illnesses. Without this, the differential remains broad and the most likely aetiology (viral pericarditis) is missed.

How should I prepare for acute pericarditis if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Actively eliciting the preceding viral illness: the patient will not mention her cold unless asked about recent infections, and this is the key aetiological link. 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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