PLAB 2 Cardiology: Mastering Acute Chest Pain Management in OSCE

Acute chest pain is one of the most frequently encountered and critical scenarios in the PLAB 2 OSCE examination. It's a high-stakes station that tests not only your clinical knowledge but also your ability to perform a structured assessment, manage immediate threats, and communicate effectively under pressure. As an examiner and medical educator, I've seen countless students navigate this scenario, and the key to success lies in a systematic approach guided by established medical guidelines.

Why Acute Chest Pain is a PLAB 2 High-Yield Topic

Chest pain can be indicative of life-threatening conditions such as Myocardial Infarction (MI), Pulmonary Embolism (PE), or Aortic Dissection. Your ability to quickly differentiate between benign and serious causes, initiate appropriate investigations, and manage acutely unwell patients is paramount. PLAB 2 tests your fitness to practice in the UK, and responding competently to a patient with chest pain is a core competency.

The Systematic Approach: ABCDE Assessment

Always begin with a rapid ABCDE assessment (Airway, Breathing, Circulation, Disability, Exposure). This ensures you identify and manage any immediate life threats before delving into detailed history or examination.

• Airway: Is it patent? Is the patient speaking full sentences?

• Breathing: Assess respiratory rate, effort, oxygen saturation. Look for symmetrical chest expansion, auscultate for breath sounds.

• Circulation: Check pulse rate, rhythm, blood pressure. Assess capillary refill time. Look for signs of shock.

• Disability: Assess consciousness level (AVPU/GCS), pupil size, focal neurological deficits.

• Exposure: Quickly inspect the chest and any other relevant areas for rashes, trauma, or swelling (e.g., DVT in PE).

Crucial History Taking for Chest Pain

While managing ABCDE, simultaneously gather a focused history. Remember to use the PQRST mnemonic to characterize the pain:

• Provoking/Palliating factors: What makes it better or worse?

• Quality: Is it crushing, sharp, tearing, burning, dull?

• Radiation: Does it spread to the arm, jaw, back, neck?

• Severity: Rate on a scale of 0-10.

• Timing: When did it start? How long does it last? Is it constant or intermittent?

Associated Symptoms are Key:

• Cardiac: Shortness of breath, palpitations, sweating, nausea, vomiting, dizziness, syncope.

• Respiratory: Cough, sputum, fever, pleuritic pain.

• Gastrointestinal: Dysphagia, heartburn, regurgitation, abdominal pain.

• Musculoskeletal: Pain on movement or palpation, localized tenderness.

Risk Factors: Enquire about smoking, hypertension, diabetes, hyperlipidemia, family history of heart disease, recent long flights/immobility (for PE), drug use (e.g., cocaine).

Targeted Clinical Examination

Based on your initial assessment and history, focus your examination:

• Cardiovascular: Listen for heart sounds (murmurs, rubs), check for peripheral oedema, JVP.

• Respiratory: Auscultate lung fields for crackles, wheeze, decreased breath sounds; check for tracheal deviation.

• Abdominal: Palpate for tenderness, guarding.

• Musculoskeletal: Palpate the chest wall, check range of motion.

Essential Investigations in the OSCE Setting

Always state the investigations you would request immediately and why. In PLAB 2, you might not perform them, but demonstrating your knowledge is vital.

• Electrocardiogram (ECG): This is critical and should be done within 10 minutes of presentation if cardiac chest pain is suspected. Look for ST elevation/depression, T wave inversion, pathological Q waves, arrhythmias.

• Blood Tests:

  • Cardiac Troponins: Essential for diagnosing myocardial injury.

  • Full Blood Count (FBC): For anaemia, infection.

  • Urea & Electrolytes (U&E): For renal function (relevant for medication choices).

  • D-dimer: If Pulmonary Embolism is suspected and Wells' score is low/intermediate (remember not to use D-dimer in high probability PE scenarios).

• Chest X-ray (CXR): To rule out pneumonia, pneumothorax, pleural effusion, heart failure, or aortic widening (in aortic dissection).

Management Principles: Tailored to Diagnosis

Once you have a working diagnosis or are awaiting results, management should follow established guidelines. Always mention involving your senior in acute, complex cases.

1. Acute Coronary Syndrome (ACS) - STEMI/NSTEMI/Unstable Angina

• Immediate Management (MONA +/- B):

  • Morphine (if pain severe): To alleviate pain and anxiety.

  • Oxygen: If saturations <94% or patient is hypoxemic.

  • Nitrates (GTN spray/IV): Vasodilator, reduces preload.

  • Aspirin: 300mg chewable stat (antiplatelet).

  • P2Y12 Inhibitor: Clopidogrel, Ticagrelor, Prasugrel (e.g., Ticagrelor 180mg stat).

• Anticoagulation: Low molecular weight heparin (LMWH) e.g., Enoxaparin.

• Beta-blockers: Oral or IV, if no contraindications.

• Reperfusion Strategy (for STEMI): Primary Percutaneous Coronary Intervention (PCI) is preferred if available within 90-120 mins; otherwise, thrombolysis.

2. Pulmonary Embolism (PE)

• Oxygen: To maintain sats >94%.

• Anticoagulation: Initiate immediately with LMWH or unfractionated heparin, then transition to oral anticoagulation (DOACs or Warfarin).

• Thrombolysis: For massive PE with haemodynamic instability.

• Senior involvement & Transfer: Discuss with seniors for further management.

3. Aortic Dissection

• Immediate pain control.

• Aggressive blood pressure control: IV labetalol or esmolol to reduce shear stress.

• Surgical Referral: Urgent consultation with cardiothoracic surgeons.

4. Pericarditis

• NSAIDs: High dose, e.g., Ibuprofen.

• Colchicine: Often added to NSAIDs for recurrent pericarditis.

• Identify underlying cause: Viral, autoimmune, etc.

5. Other Causes (e.g., GORD, Musculoskeletal Pain)

• GORD: Antacids, PPIs, lifestyle advice.

• Musculoskeletal: Analgesia, rest, physiotherapy referral.

• Reassurance: If serious causes are ruled out.

Communication Skills in the OSCE

Your communication is half the battle. Remember to:

• Introduce yourself clearly and explain your role.

• Empathize with the patient's pain and anxiety.

• Explain your assessment process and what you are doing in simple terms.

• Be transparent about potential diagnoses and your plan.

• Involve the patient in the decision-making process where appropriate.

• Safety netting: Advise on when to seek immediate medical attention again (e.g., worsening pain, new symptoms).

• Discuss with seniors: Clearly state you will escalate the case to your senior registrar/consultant.

PLAB 2 Specific Tips

• Time Management: Acute scenarios are often time-pressured. Practice efficient history taking and examination.

• Prioritisation: Always manage life threats first (ABCDE).

• Differential Diagnoses: Think broadly initially, then narrow down as you gather more information.

• Say what you are doing: Narrate your thoughts and actions to the examiner.

• Be confident but humble: Demonstrate confidence in your knowledge, but know when to ask for help from seniors.

Mastering the acute chest pain scenario in PLAB 2 requires a blend of sharp clinical skills, up-to-date knowledge of guidelines, and excellent communication. By following a structured approach and practicing regularly, you can confidently manage this critical presentation and ace your exam. Good luck!