Exertional chest pain — angina history
PLAB 2 & PRES 3 · cardiology · medium · 8 minutes
Candidate brief
You are an FY2 doctor in the Emergency Department. Mr David Hughes, 58, has been referred by his GP with chest pain on exertion over the past three weeks. He is currently pain-free. His ECG shows sinus rhythm with no ischaemic changes, and his observations are stable. Take a focused history of the chest pain, explore his risk factors, and then discuss your likely diagnosis and management plan with him.
What examiners look for
Typical angina has three features: constricting discomfort in the front of the chest, neck, shoulders, jaw or arms; precipitated by physical exertion; and relieved within minutes by rest or by GTN. All three present = typical angina; two = atypical; one or none = non-anginal chest pain, in NICE terms. Relief with GTN supports angina but does not confirm it, and lack of relief does not rule it out — oesophageal spasm can also respond to GTN, and severe coronary disease may not. Pain that is new, occurring at rest, crescendo in pattern, or prolonged is unstable until proven otherwise and changes the pathway entirely: this patient is pain-free with a stable three-week exertional pattern, which is why an urgent but non-emergency cardiology assessment is the right shape of plan. Risk factors are part of the diagnosis, not small talk: age, male sex, smoking, hypertension, diabetes, hyperlipidaemia and a family history of premature coronary disease all shift the probability before any test is done. A normal resting ECG does not exclude stable angina. It is expected in many patients between episodes. Medication adherence matters clinically: "most days" amlodipine is uncontrolled hypertension wearing a prescription. Ask without blame — the reasons are usually practical. His father's death at 60 is doing double work in this station: it is a genuine risk factor AND the source of his fear. Candidates who address only the fact and not the fear score less on communication. Safety-netting is a marking point, not a pleasantry: pain at rest, pain lasting beyond 15 minutes, or pain with collapse or severe breathlessness means call 999, stated explicitly. Driving and heavy manual work should be discussed honestly: he must stop and seek help if pain comes on, avoid exertion that provokes it until assessed, and follow the cardiology team's advice — do not invent specific DVLA rules for stable angina in the station; if asked, say the specialist team will advise.
Guideline references
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