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 + cardiovascular/respiratory examination + initial plan
Setting: Emergency department

Your task

Take a focused chest-pain history and perform a focused cardiovascular and respiratory examination. At the end, summarize the leading diagnosis, dangerous alternatives, immediate investigations and initial management. You have 11 minutes.

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, examine efficiently for instability and dangerous alternatives, and begin urgent care without delaying the ECG.

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.

Complete 11-minute examination procedure

Use the sequence as a structured guide. In a real station, adapt immediately to the task and the patient’s stability.

0:00–0:40

Introduce yourself, identify the patient and obtain consent

Suggested wording: “Hello, my name is Dr. ____. I am one of the doctors working in the emergency department. Could I confirm your full name and date of birth? I understand you have chest pain. I would like to ask a few focused questions and examine your heart and lungs. Is that okay?”

Stand at eye level, use the patient’s preferred name and maintain calm eye contact.
Confirm identity using two identifiers.
Explain the purpose and scope of the examination in plain language.
Obtain verbal consent and offer to stop if pain or breathing worsens.

0:40–1:00

Hand hygiene, pain check and immediate safety screen

Suggested wording: “I am going to clean my hands first. Before I begin, how severe is the pain now? Are you feeling faint or more short of breath?”

Perform visible hand hygiene before touching the patient.
Ask about current pain and distress before positioning or palpation.
If the patient appears unstable, call for urgent help and begin an ABC assessment rather than continuing a routine sequence.

1:00–1:25

Position, exposure and dignity

Suggested wording: “I need to examine your chest. I will keep you covered as much as possible. Please let me know if any movement increases your pain.”

Position the patient at approximately 45 degrees unless clinical status requires another position.
Expose the anterior chest sufficiently for examination while using a gown or drape.
Avoid unnecessary exposure and ensure the patient remains comfortable.

1:25–2:00

General inspection and ABC-focused assessment

Suggested wording: “I am first looking at your breathing and overall condition.”

Observe distress, diaphoresis, pallor, cyanosis, respiratory effort and ability to speak.
Review the provided heart rate, blood pressure, respiratory rate, oxygen saturation and temperature.
State that severe instability would trigger immediate resuscitation, monitoring and senior help.

2:00–2:45

Hands, pulse and perfusion

Suggested wording: “I am checking your pulse and circulation now.”

Assess hand temperature, colour and capillary refill.
Palpate the radial pulse for rate, rhythm and volume.
Compare radial pulses for symmetry when dissection is a concern.
State that blood pressure in both arms is appropriate if the history suggests aortic dissection.

2:45–3:30

Face and neck

Suggested wording: “I am going to look at your face and neck for signs that may help explain the chest pain.”

Inspect for conjunctival pallor and central cyanosis.
Assess the jugular venous pressure with the patient at about 45 degrees.
Palpate one carotid at a time only when clinically appropriate; auscultate for a bruit if indicated.
Do not perform simultaneous bilateral carotid palpation.

3:30–5:30

Focused precordial examination

Suggested wording: “I am now going to inspect, feel and listen over your heart. Please tell me if anything is uncomfortable.”

Inspect for scars, deformity, visible pulsations and implanted devices.
Palpate the apex beat and assess for displacement.
Check for a parasternal heave and palpable thrills.
Auscultate the aortic, pulmonic, tricuspid and mitral areas with the diaphragm; use the bell at the apex when indicated.
Identify S1 and S2 and assess for murmurs, rubs or extra heart sounds.
Use additional manoeuvres only when a specific finding requires clarification.

5:30–7:00

Focused respiratory examination

Suggested wording: “I am going to examine your lungs now. Please take slow deep breaths through your mouth when I ask.”

Inspect respiratory rate, symmetry and accessory-muscle use.
Assess tracheal position and chest expansion if indicated.
Percuss and auscultate the anterior chest and lung bases, comparing both sides.
Listen for crackles suggesting pulmonary edema, reduced air entry or wheeze.
Stop if deep breathing worsens pain or distress.

7:00–7:45

Peripheral cardiovascular and thromboembolic signs

Suggested wording: “I am checking your legs briefly for swelling or circulation problems.”

Inspect for peripheral edema and compare the calves for asymmetry.
Look for unilateral swelling or erythema suggestive of venous thromboembolism.
Avoid forceful calf squeezing or relying on Homan sign.
Assess peripheral pulses when indicated.

7:45–8:15

Complete the examination respectfully

Suggested wording: “Thank you. The examination is finished. I will help you sit comfortably and cover you again.”

Replace the gown or drape and return the patient to a comfortable position.
Perform hand hygiene after the examination.
Thank the patient and check whether pain or breathing has changed.

8:15–9:15

Describe the findings clearly

Suggested wording: “The patient is anxious and mildly diaphoretic but not hypoxemic. The pulse is regular and mildly tachycardic with equal radial pulses. JVP is not elevated. The apex is not displaced, there are no heaves or thrills, and heart sounds are normal without a new murmur or rub. The lungs are clear, and there is no unilateral leg swelling.”

Report pertinent positive and negative findings in a concise system-based order.
Do not invent findings that were not provided or elicited.
Link findings to the leading diagnosis and dangerous alternatives.

9:15–11:00

Summarize, prioritize and answer examiner questions

Suggested wording: “This presentation is acute coronary syndrome until proven otherwise. I would obtain an immediate 12-lead ECG without delaying for a prolonged examination, place the patient on cardiac monitoring, establish IV access, send serial high-sensitivity troponin and baseline blood work, give antiplatelet therapy if safe, treat symptoms appropriately and activate the reperfusion or cardiology pathway if indicated. I would continue to consider aortic dissection and pulmonary embolism based on the history and examination.”

State the leading diagnosis first.
Name dangerous alternatives and the findings that would increase concern.
Prioritize urgent investigation and management rather than giving a long unranked list.
Answer examiner prompts directly and stop when the station signal sounds.

Physical findings

General: anxious, mildly diaphoretic and uncomfortable; speaking in full sentences; no central cyanosis.
Perfusion: hands warm, capillary refill under 2 seconds; radial pulse 102/min, regular and equal bilaterally.
Neck: jugular venous pressure not elevated.
Precordium: no scar or visible pulsation; apex beat not displaced; no parasternal heave or thrill.
Auscultation: normal S1 and S2; no new murmur, pericardial rub or gallop.
Respiratory: equal air entry; no crackles, wheeze or focal reduction in breath sounds.
Periphery: no ankle edema; no unilateral calf swelling, erythema or tenderness.

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

Introduces self, confirms identity and obtains consent before touching the patient.
Explains each stage of the examination and checks comfort throughout.
Maintains modesty with limited exposure and appropriate draping.
Acknowledges fear without minimizing symptoms and uses short, clear sentences.
Thanks the patient, restores comfort and summarizes the next urgent steps.

Critical safety actions

Do not delay an immediate ECG or urgent treatment for a prolonged history or full physical examination.
Escalate immediately if the patient becomes hypotensive, hypoxemic, confused or increasingly distressed.
Recognize ongoing ischemic pressure with autonomic symptoms as acute coronary syndrome until proven otherwise.
Check medication and bleeding contraindications before nitrates, antiplatelet or antithrombotic therapy.
Consider dissection before giving antithrombotic therapy when tearing pain, pulse deficit, neurologic deficit or marked inter-arm blood-pressure difference is present.

Model closing summary

This 58-year-old man has 40 minutes of ongoing exertional central pressure radiating to the left arm and jaw with diaphoresis, nausea, dyspnea and major cardiovascular risk factors. He is mildly tachycardic but currently normoxic, with equal pulses, no new murmur, clear lungs and no unilateral leg swelling. Acute coronary syndrome is most likely. I would obtain an immediate ECG without delaying for a prolonged examination, begin monitoring and IV access, send serial high-sensitivity troponin and baseline blood work, give appropriate antiplatelet therapy if safe, treat symptoms, and activate the reperfusion or cardiology pathway if indicated. Aortic dissection and pulmonary embolism remain dangerous alternatives.

Common pitfalls

Skipping identity, consent, hand hygiene or pain assessment.
Exposing the patient more than necessary or failing to explain examination actions.
Performing a ritual full-body examination instead of a focused cardiovascular and respiratory examination.
Spending so long examining that the ECG and urgent management are delayed.
Calling the pain reflux before excluding acute coronary syndrome.
Routine oxygen despite normal saturation.
Reporting invented findings or giving a long unprioritized differential.

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

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