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Home / Station 1: Chest pain in a 58-year-old

NAC OSCE preparation

Station 1: Chest pain in a 58-year-old

Complete the task in 11 minutes. Reveal the full standardized-patient script, examiner prompts and structured debrief only after your attempt.

Station time

11:00

Ready for an 11-minute attempt.

Candidate instructions

Chest pain in a 58-year-old

11 minutes

Discipline: Internal Medicine
Station type: Focused history + initial plan
Setting: Emergency department

Your task

Take a focused history. At the end, summarize the leading diagnosis, dangerous alternatives, immediate investigations and initial management. Do not perform a physical examination.

Information available at entry

HR 102/minBP 154/92 mm HgRR 20/minSpO₂ 96% room airT 36.8°C

Coach prompt: Recognize acute coronary syndrome and immediately dangerous alternatives.

In Exam Mode, coaching cues are hidden. Ask a partner to use the standardized-patient script after you start the timer.

Finished your attempt?Reveal the full station only after completing or stopping the timer.

Complete station package

Standardized-patient script and structured debrief

Station 1 of 30

Standardized-patient profile

NameMr. Daniel Lee

Age58

Pronounshe/him

RolePatient

Demeanour: Anxious, mildly diaphoretic.

Opening statement: “Doctor, I have a heavy pressure in the middle of my chest that started about 40 minutes ago.”

History and standardized-patient responses

Presenting symptom

Candidate explores	Standardized-patient response
Onset/activity	Sudden while carrying groceries upstairs, 40 minutes ago.
Character/radiation	Central heavy pressure radiating to left arm and jaw.
Severity/course	8/10, continuous, not settling with rest.
Associated symptoms	Sweating, nausea and dyspnea; no syncope.
Modifiers	Worse with exertion; unchanged by breathing, movement or palpation.

Dangerous alternatives

Candidate explores	Standardized-patient response
Dissection features	No tearing pain or back radiation.
PE features	No pleuritic pain, hemoptysis, recent surgery, immobilization or prior VTE.
Other	No fever, cough or repeated vomiting.

Risk/background

Candidate explores	Standardized-patient response
Risk factors	Hypertension, dyslipidemia, type 2 diabetes, smoking; father had MI at 54.
Medication/allergy	Metformin, ramipril, atorvastatin; no allergies or PDE-5 inhibitor use.
Bleeding risk	No active bleeding, intracranial hemorrhage or recent major surgery.

Physical findings

Clammy and uncomfortable.
Regular tachycardia; no new murmur.
Chest clear; equal pulses; no unilateral leg swelling.

Examiner prompts

Leading diagnosis?

Acute coronary syndrome until ECG and troponin clarify STEMI versus NSTEMI/unstable angina.

Immediate steps?

Urgent help, monitoring, IV access, immediate 12-lead ECG, troponin and baseline blood work, antiplatelet therapy if safe, symptom treatment and reperfusion pathway if STEMI.

Two dangerous alternatives?

Aortic dissection and pulmonary embolism; consider tension pneumothorax or esophageal rupture when supported.

Differential diagnosis

Acute coronary syndrome
Aortic dissection
Pulmonary embolism
Tension pneumothorax
Pericarditis
Esophageal disease

Investigations

Immediate ECG and continuous monitoring
Serial high-sensitivity troponin
CBC, electrolytes, renal function and glucose
Chest radiograph or advanced imaging only when indicated

Management

Monitored emergency care
Antiplatelet therapy if no contraindication
Treat ischemia and blood pressure appropriately; oxygen only if hypoxemic
Activate cardiology/reperfusion pathway when indicated
Secondary prevention after stabilization

Communication behaviours

Acknowledge fear without minimizing symptoms
Use short, clear sentences while urgent care proceeds

Critical safety actions

Do not delay ECG for a long history
Recognize ongoing ischemic pressure with autonomic symptoms
Check contraindications before nitrates or antithrombotic therapy

Model closing summary

This 58-year-old man has 40 minutes of ongoing exertional central pressure radiating to the arm and jaw with diaphoresis and major cardiovascular risk factors. Acute coronary syndrome is most likely. I would monitor him, obtain IV access and an immediate ECG, send serial troponin and baseline blood work, give appropriate antiplatelet therapy if safe, and activate the reperfusion/cardiology pathway if indicated. Aortic dissection and PE remain dangerous alternatives.

Common pitfalls

Calling pain reflux before excluding ACS
Routine oxygen despite normal saturation
Long unprioritized differential
Forgetting bleeding and medication contraindications

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

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