Station 52
Micheal Starmer
Age: 51 years old male
Full Case
Patient’s Data
Patient’s name: Micheal Starmer
Age: 51-year-old male
Past medical history
- Hypertension
- Hypercholesterolaemia
Drug and Allergy History
- Ramipril 10 mg once daily
- Atorvastatin 20 mg at night
- No Known drug Allergy
Recent Notes/ Consultations
- Nil
Patient has booked an urgent telephone appointment to discuss ongoing concerns.
Patient's Story (Role player’s brief)
Patient’s Story
You are Michael Starmer, a 51-year-old accountant. You’ve booked this urgent telephone appointment due to recent episodes of chest pain.
Opening statement: Hi Doctor, thanks for calling. I’ve had some chest pain since yesterday; it started about 11 hours ago. It felt a bit like heartburn at first but then turned into a dull ache. It lasted for about 30 minutes and has happened again today while I was helping my boss at work move some files and shift his desk.
If asked to explain further:
The first episode started approximately 11 hours ago. It felt initially like heartburn, then developed into a dull ache in your chest. The pain lasted about 30 minutes and occurred while you were at rest watching tv. It was accompanied by shortness of breath and palpitations (heart racing).
You’re currently at work and experienced another similar episode around 40 minutes ago prior to this call. It came on while helping your boss move some paper files and shift his desk. It lasted for 30 minutes
You are not experiencing any chest pain right now. It has eased off. You suspect it might be a muscle strain, but your wife urged you to call the GP just to be safe.
Social History: You do not smoke or drink alcohol. Your diet is poor (eating mostly junk foods), and you work a sedentary job as an accountant. You do not exercise
Family history: Your uncle had a heart attack at age 42.
Ideas: You think the chest pain might just be a pulled muscle or indigestion, especially since it happened while moving things around at work.
Concerns: You’re slightly worried because it keeps coming back, and your wife is particularly anxious, especially with your uncle having had a heart attack at 42.
Expectations: You want to know if it’s anything serious and whether you need any tests or pain killers
If the doctor advises hospital admission, politely ask: “Would it be okay if I drive myself to the hospital instead?”
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the nature of the pain – whether it’s dull, sharp, pressure-like, or crushing.
- Ask about the location of the pain and whether it’s central, left-sided, or anywhere else.
- Ask if the patient is currently experiencing chest pain and when the last episode occurred.
- Ask how long each episode of chest pain has lasted.
- Ask about relieving factors, such as whether pain improves with rest or position change.
- Ask if the pain radiates to the jaw, neck, shoulders, arms, or back.
- Ask about associated symptoms such as shortness of breath, palpitations, dizziness or lightheadedness, nausea, or sweating.
- Ask about fever to help rule out infective or inflammatory causes (e.g., pericarditis, pneumonia).
- Ask about any family history of heart attack, stroke, or sudden cardiac death (especially under age 60).
- Ask about lifestyle factors, including smoking, alcohol consumption, dietary habits, occupation, and stress levels.
- Give a diagnosis of Acute Coronary Syndrome
Example of explanation to patient
Michael, based on the symptoms you’ve described, particularly the chest pain, shortness of breath, and palpitations, I’m concerned that you could be experiencing a heart attack. This happens when one of the blood vessels supplying your heart becomes blocked, which can stop oxygen from reaching part of your heart muscle. If not treated quickly, it can cause serious damage.
I strongly recommend that you go to the hospital immediately so they can carry out urgent tests, including an ECG, which is an electrical tracing of your heart, to check for any signs of damage. They will also do a blood test to check for something called troponin. Troponin is a marker that can rise when the heart muscle is under stress or has been damaged.
If the results suggest a heart attack, you may need treatment to help reopen the blocked artery and protect your heart. The sooner we act, the better the outcome.
Please do not drive yourself to the hospital, I’ll arrange for an ambulance to come and take you from your current location urgently. You mentioned you’re at your workplace, we don’t have that address on file, so I’ll need to take it down to inform the ambulance service. Is there anyone with you? If so, please let them know what’s going on. If you experience any further chest pain before help arrives, they should call 999 immediately.
Once you’re discharged from hospital, please book a follow-up appointment with us. We can then talk about lifestyle changes, like diet changes and exercise, that can help improve your heart health. We’ll also review any new medications you’ve been prescribed and make sure everything is coordinated properly.
Management
Management
- Offer emergency admission to hospital via 999- clearly advise the patient that you will arrange an ambulance and that they should not drive or make their own way to the hospital.
- Advise that if another episode of chest pain occurs while waiting for the ambulance, they should immediately call 999.
- Ask if there is someone with them and advise that the person should be informed of the situation and stay with the patient in case their condition worsens.
- Request the postcode of the patient’s workplace, since he is currently at work. This is essential for ambulance dispatch.
- Explain that once in hospital, they will perform an ECG (an electrical tracing of the heart) and a blood test to check for a chemical called troponin, which is released when the heart is under stress. If the initial investigations suggest a heart attack, the specialist team will offer treatment to help unblock the affected blood vessels and restore blood flow to the heart.
- Advise the patient to book a follow-up appointment after discharge to review the hospital findings, discuss any new medications, and explore lifestyle changes such as improving diet, exercise, and managing stress.
Learning point from this station:
Cardiac causes of chest pain include:
- Acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (STEMI and NSTEMI)
- Stable angina
- Other cardiac conditions such as aortic dissection, pericarditis, cardiac tamponade, myocarditis, acute heart failure, and arrhythmias
Important distinctions
Acute coronary syndrome (ACS)
- Acute Coronary Syndrome (ACS) includes unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI).
- Suspect ACS if the patient describes chest pain lasting longer than 15 minutes, especially when it radiates to other areas such as the arms, back, or jaw.
- The pain is typically described as dull, central, and/or crushing, and is often associated with symptoms such as nausea, vomiting, sweating, or breathlessness.
- Importantly, in ACS, pain may occur at rest or with minimal exertion.
Stable Angina (Also known simply as Angina)
- Stable angina usually presents with chest pain that occurs predictably with physical exertion or emotional stress and is relieved within about 5 minutes by rest or sublingual glyceryl trinitrate (GTN).
- Chest pain is usually described as a tight, constricting discomfort felt in the front of the chest, and possibly radiating to the neck, shoulders, jaw, or arms.
- It does not occur at rest.
If chest pain occurs at rest, think unstable angina or other acute coronary syndromes.
Management of Acute Coronary syndrome sounding chest pain for remote consultation
General guide to Chest Pain Triage
- Ongoing chest pain or pain that started just before the patient contacted you
→ Call 999 immediately. This is a medical emergency requiring urgent ambulance transfer.
- Chest pain occurred within the last 12 hours but is not present at the time of the call → Offer same-day emergency admission. Use clinical judgement to determine the safest route of admission. If appropriate, the patient may be admitted via 999, or if the patient has a responsible adult who can drive them safely, they may go in directly but provide clear safety-netting to call 999 if symptoms return or worsen during the journey to hospital. The patient should never drive themselves or travel alone.
- Chest pain occurred between 12 and 72 hours ago → Offer same-day assessment, usually via the acute medical unit (AMU) or a same-day cardiology assessment service, depending on local pathways.
- Chest pain occurred more than 72 hours ago → Refer to the Rapid Access Chest Pain Clinic (RACPC) to be seen within 1 to 2 weeks. Provide robust safety-netting, advising the patient to call 999 immediately if chest pain recurs.