Acute chest pain in the GP surgery — suspected heart attack
PLAB 2 & PRES 3 · cardiology / emergency medicine · hard · 10 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mr Paul Donnelly, 57, walked into reception 10 minutes ago complaining of chest pain and has been brought straight through to your room. The pain started 40 minutes ago while he was climbing stairs at home. Your practice nurse is available to help, and the surgery has an ECG machine, oxygen, aspirin, GTN, and a defibrillator. Observations: respiratory rate 20/min, SpO2 96% on air, pulse 104/min regular, BP 148/92 mmHg, temperature 36.8 °C. He looks pale and sweaty. Please assess and manage this patient.
What examiners look for
In the GP surgery, the diagnosis is made by suspicion and confirmed by ECG — and neither may delay the ambulance. The single most scored behaviour in this station is an early 999 call; everything else happens around a transfer that is already moving. Ask the questions that change what you give, not the questions that complete the form. Allergy, bleeding risk, anticoagulants, other medicines — four questions stand between this man and his aspirin. The rest of the history can be taken while the nurse applies the ECG leads. Oxygen is a drug with a target, not a ritual. At 96% on air it adds nothing and, given thoughtlessly in MI, can harm. Candidates who reach for the mask before the saturations demonstrate habit; candidates who state the target range demonstrate medicine. Read the ECG out loud. Saying "inferior STEMI — ST elevation in II, III and aVF" to the room, the call handler and the crew is what routes this man to a catheter lab instead of a general medical take, and it is the moment the station turns. He walked in because he didn't want a fuss — so the two lethal courtesies are letting him walk to the ambulance and letting his wife drive him "to save time". Wheelchair or trolley, defibrillator alongside, wife brought in and told. Politeness is not a management plan. Answer the dying question properly. "Am I going to die?" deserves a seated, honest ten seconds: it is a heart attack, it is serious, speed is why everyone is moving fast, and he has done the right thing by coming in. False cheer and grim silence both fail a frightened man at the exact moment he asked. Handover is treatment. Onset time, aspirin time, ECG diagnosis, what was given and what it did — the crew and the PCI team can only act on what you transmit, and in STEMI the clock you describe is the myocardium you save.
Guideline references
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