Summary of Common Conditions Seen in OSCEs
| ‘Red flags’ | Common errors | |
| Acute coronary syndrome (ACS) | Past medical history of ACS | Mistaking pain from an aortic dissection for an ACS. The management of aortic dissection and ACS are completely different so it is imperative to be sure what you are dealing with before implementing a management plan. Thrombolysing a dissecting aneurysm will result in death, so if unsure mention that you would do a CT scan to rule out dissection |
| Central crushing pain | ||
| Radiation to left arm and/or jaw | ||
| Not relieved by GTN spray in a known angina sufferer | ||
| Aortic dissection | Tearing central pain of sudden onset radiating to the back | |
| Past medical history of hypertension | ||
| Past medical history and/or family history of connective tissue disease, e.g. Marfan syndrome | ||
| Pneumothorax | Young male typically in teens or twenties | |
| Sudden onset | ||
| Associated with shortness of breath | ||
| Pulmonary embolism | Positive risk factors | Assuming that pulmonary embolism has been ruled out if there are no symptoms of a deep vein thrombosis (DVT). Remember that a significant proportion of DVTs are initially asymptomatic or cause only mild discomfort, and most pulmonary embolisms occur without clinical evidence of a DVT |
| Past medical history of pulmonary embolism | ||
| Family history of thrombophilia | ||
| Pain increased by inspiration | ||
| Associated with red, swollen, painful leg | ||
| Pneumonia | Cough productive of green/blood-stained phlegm | Chest pain alone is an uncommon presenting symptom of pneumonia so ensure you have ruled out all the other causes listed in this table before diagnosing this |
| Recent upper respiratory tract infection | ||
| Pericarditis | Pain improved by sitting forward | Any of the ‘red flags’ may be ‘red herrings’ so it is important to take a thorough history to rule out ACS and other diagnoses even if pericarditis is strongly suspected from the history |
| Fever or recent viral illness | ||
| Recent myocardial infarction (associated with Dressler’s syndrome) | ||
| Past medical history of rheumatoid arthritis, SLE, sarcoid or radiotherapy | ||
| Peptic ulcer disease or gastritis | Associated symptoms include dysphagia, acid reflux, weight loss and melaena | About 1 in 10 patients diagnosed with ‘gastritis’ in A&E actually have inferior myocardial infarction, so even if gastritis is strongly suspected from the history, you must do an ECG to rule out inferior myocardial infarction |
| Drug history includes NSAIDs, steroids or any other drugs that predispose to peptic ulcer disease | ||
| Location of pain is epigastric with retrosternal radiation | ||
| Ruptured oesophagus | Upper gastrointestinal endoscopy in the last 48 hours | Recent endoscopy could be a ‘red herring’ so rule out other causes before settling on this rare condition |
| Violent vomiting, e.g. after an alcohol binge | ||
| Costochondritis | Point tenderness when asked about site of pain | Settling with these diagnoses without ruling out life-threatening differential diagnoses through appropriate questioning |
| Shingles | Associated with rash | |
| Pain radiating out across chest in a dermatomal distribution | ||
| Pain made worse by contact with clothing |
Hints and Tips for the Exam
History of chest pain is an examiner’s favourite because it is a common presenting complaint, there are a wide range of differential diagnoses and it should have been practised by students on numerous occasions on clinical attachments. But beware – this is not an easy station because forgetting to ask the key questions (as candidates often do) will be deemed unsafe and can prevent you passing. The essentials to pass this station and common pitfalls to avoid are as follows.
Key Points to Demonstrate Safety
- You MUST ask questions to rule out ALL the potentially life-threatening causes of chest pain even if you have a good idea of what the diagnosis is after your first question.
- Establish risk factors for ischaemic heart disease. These are listed on the mark sheet but don’t forget that the name and age of the patient can provide valuable information. Age >55 years and being of South-Asian origin substantially increases the risk of ischaemic heart disease.
- Beware of red herrings. A flu-like illness 3 weeks previously does not necessarily mean that a patient is suffering from pericarditis. You must rule out other causes.
- If asked about management, remember the importance of resuscitating the patient with respect to airway, breathing and circulation before implementing more complex management plans aimed at correcting the underlying cause of the chest pain.
- When eliciting the past medical history, beware of conditions that may contraindicate the use of certain drugs. For example, a patient with myocardial infarction and a past medical history of cerebral neoplasm cannot be treated with thrombolytic drugs. Such knowledge will be expected from candidates to be considered for merits.
Key Points to Demonstrate Good Communication Skills
- Start with an open question such as ‘How can I help you?’ even if an acute situation is being simulated. Allowing the actor-patient to express themselves initially will usually give you a good indication of the diagnosis. Closed questions can subsequently be used to rule out each of the other potentially life-threatening conditions and their risk factors.
- Do not forget to ask the actor-patients about their main concerns. You will typically be asked what you think is causing the chest pain, or what will happen next. It is important to use phrases that demonstrate empathy, but you must NOT provide false reassurance that everything is fine if you are suspecting a serious diagnosis – this could result in a fail.
- Do NOT miss out on opportunities to demonstrate empathy. Actor-patients often give cues such as mentioning bereavement during the family history. It is a good idea to briefly express commiseration by saying ‘I’m sorry to hear that’ before moving on.
Questions You May Be Asked
Q. If you were an FY1 doctor in A+E, how would you hand this patient with central crushing chest pain over to the cardiology team?
A. See Chapter 56 on the handover.
Q. Take a history of this patient presenting with chest pain and interpret the ECG shown to you by the examiner.
A. The answer to this obviously depends on the specific case.
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