History Taking · Foundation · Cardiovascular

Sudden Severe Chest Pain with Risk Features

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

Clinical scenario

You are an FY2 doctor in an acute medical assessment unit. Mr William Hartley, a 71-year-old man with hypertension, presents with sudden-onset tearing chest pain radiating to his back, severe and unrelenting. He appears acutely unwell. Take an urgent focused history and discuss immediate management plan for suspected aortic dissection, including imaging and emergency referral.

Background notes: PMH: Hypertension, Chronic kidney disease stage 3b, Hyperlipidaemia

What this station tests

  • Recognising the classic aortic dissection presentation: sudden onset with maximal severity, tearing character, interscapular radiation, unrelenting duration
  • Distinguishing dissection from MI rapidly: onset pattern (sudden maximal versus building), character (tearing versus heavy), radiation (back versus arm), and temporal pattern
  • Screening for dissection complications: neurological deficit (carotid), limb ischaemia (subclavian/iliac), abdominal pain (mesenteric), syncope (tamponade)
  • Communicating urgency and a life-threatening diagnosis clearly to a frightened patient while maintaining calm professionalism
  • Identifying medication non-adherence as a modifiable risk factor without being judgmental in an acute setting

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

Emergency history taking stations test whether candidates can adapt their approach to clinical urgency. A full systematic history is inappropriate here. Mr Hartley is 71, acutely unwell, in severe pain, brought by ambulance 45 minutes after sudden-onset tearing chest pain. Your history must be rapid and focused. Confirm identity briefly, then go straight to the pain: 'Mr Hartley, I can see you are in a lot of pain. Can you describe exactly what happened and what the pain feels like?' The urgency of your manner should match the clinical situation.

Core approach

The key discriminators for aortic dissection are: sudden onset with maximal severity at onset (unlike ACS, which builds gradually), tearing or ripping character ('like something tearing apart inside my chest'), radiation to the back between the shoulder blades (interscapular, unlike ACS which radiates to the arm), severity 10/10 ('worst pain I've ever felt'), and continuous, unrelenting duration for 45 minutes. He was sitting watching TV when it started, with no exertional trigger and no prodrome.

Take a targeted risk factor history. Hypertension for 20 years with poor adherence to amlodipine (takes it intermittently). Uncontrolled hypertension is present in approximately 90% of aortic dissections. Current smoker, 20/day for 40 years. CKD stage 3b. No statin despite hyperlipidaemia. His father died suddenly at 68 with an unclear cause, possibly an aortic event.

Screen for complications of dissection, which indicate extent and urgency. Any weakness or speech difficulty (carotid involvement)? Any difference between the arms (subclavian)? Any leg weakness or cold legs (iliac)? Any abdominal pain (mesenteric ischaemia)? Has he fainted (suggests tamponade or rupture)? He has dizziness and feels faint, which is concerning. No focal neurology.

Closing and safety netting

Communicating a life-threatening diagnosis requires clarity and calm. 'Mr Hartley, I believe you may have a tear in the main blood vessel coming from your heart. This is called an aortic dissection and it is a medical emergency. We need an urgent CT scan to confirm this, and I am contacting the cardiothoracic surgeons now.'

Immediate management: IV access, aggressive blood pressure control targeting systolic below 120 (IV labetalol), pain control (IV morphine), continuous monitoring. CT angiography is the definitive investigation. Type A (ascending aorta) requires emergency surgery. Type B (descending only) may be managed medically. Crucially, do not give antiplatelet or anticoagulant therapy, which would be appropriate for ACS but catastrophic in dissection.

He lives alone, is divorced, has minimal family contact. Ask if there is someone to call. Acknowledge his fear: 'I know this is very frightening. We are going to look after you and get the treatment you need as quickly as possible.' Do not discuss detailed prognosis now. The priority is diagnosis and treatment.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute aortic dissection. 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: Rapid, focused SOCRATES identifying dissection features: sudden maximal onset, tearing character, interscapular radiation. Targeted risk factor assessment: uncontrolled hypertension, smoking, age. Complication screening: neurology, limb perfusion, abdominal symptoms, syncope. Medication non-adherence identified.

Costs marks: Slow, unfocused history inappropriate for the clinical urgency. Not distinguishing dissection from MI features. Not screening for complications. Missing the significance of 20 years of poorly controlled hypertension.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct identification of aortic dissection as working diagnosis. Immediate management: IV access, aggressive BP control (target SBP <120, IV labetalol), analgesia, CT angiography. Emergency cardiothoracic referral. Understanding Type A versus Type B and the surgical implication. Not giving antiplatelet or anticoagulant therapy.

Costs marks: Treating as ACS with aspirin and anticoagulation (potentially catastrophic in dissection). Not requesting CT angiography. Not contacting cardiothoracic surgery. Vague management plan in a time-critical emergency.

Domain 3: Interpersonal Skills (Important but adapted to emergency)

Scores well: Clear, honest communication of a life-threatening diagnosis without causing panic. Calm professionalism that matches the urgency. Asking if there is someone to contact (he lives alone, divorced). Brief acknowledgment of his fear. Appropriate pace: fast enough for the emergency, human enough for the patient.

Costs marks: Being so clinical that the patient feels like a diagnosis rather than a person. Not acknowledging his fear. Not asking about next of kin. Providing detailed prognosis inappropriately in an acute setting.

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. Treating this as a standard history taking station with full social history, family history, and ICE exploration. This is a medical emergency. Spending 4 minutes on systematic history and social history is inappropriate. The history must be rapid and focused on confirming the diagnosis and identifying complications. ICE should be brief and embedded within the clinical conversation.
  2. Misdiagnosing as acute MI. The pain is tearing (not heavy), maximal at onset (not building), radiates to the back (not the arm), and started at rest. Candidates who default to the ACS pathway without recognising the dissection pattern will propose inappropriate treatment (antiplatelet and anticoagulant therapy, which would worsen an aortic dissection).
  3. Not screening for end-organ complications. Aortic dissection can cause stroke (carotid involvement), limb ischaemia, renal failure, or mesenteric ischaemia depending on the extent of the dissection. Candidates who do not ask about neurological symptoms, limb sensation, and abdominal pain miss the assessment of dissection extent.

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 acute aortic dissection history in PLAB 2?

Emergency history taking stations test whether candidates can adapt their approach to clinical urgency. A full systematic history is inappropriate here. Mr Hartley is 71, acutely unwell, in severe pain, brought by ambulance 45 minutes after sudden-onset tearing chest pain.

Where are marks won and lost in this acute aortic dissection station?

Examiners reward: Rapid, focused SOCRATES identifying dissection features: sudden maximal onset, tearing character, interscapular radiation. Targeted risk factor assessment: uncontrolled hypertension, smoking, age. Candidates are penalised for: Slow, unfocused history inappropriate for the clinical urgency. Not distinguishing dissection from MI features. Not screening for complications.

Where do candidates most often go wrong in this station?

Treating this as a standard history taking station with full social history, family history, and ICE exploration. This is a medical emergency. Spending 4 minutes on systematic history and social history is inappropriate.

Can I do well in this station without real-world experience of acute aortic dissection?

This station rewards process over personal experience. The skill being assessed: Distinguishing dissection from MI rapidly: onset pattern (sudden maximal versus building), character (tearing versus heavy), radiation (back versus arm), and temporal pattern. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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