PLAB 2 Chest Pain Station: How to Approach, Mark Scheme & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
  The deadliest cause and the one PLAB is testing - central crushing pain, often radiating to the jaw or left arm, associated with sweating, nausea or breathlessness, on a background of cardiovascular risk factors.
• Pulmonary embolism
  Pleuritic chest pain with breathlessness, sometimes haemoptysis, on a background of recent immobility, surgery, malignancy, pregnancy or oral contraceptive use. Use a Wells score before requesting a D-dimer.
• Aortic dissection
  Sudden tearing chest pain radiating through to the back, often with unequal blood pressures between the arms or unequal pulses. Rare but instantly fatal - actively rule it out in any sudden severe chest pain.
• Pericarditis or myocarditis
  Sharp, positional pain, worse on lying flat and on deep inspiration, eased by sitting forward. Often a recent viral illness.
• Tension or spontaneous pneumothorax
  Sudden unilateral pleuritic pain with breathlessness, classically in a tall thin young man or a known COPD/asthma patient.
• Musculoskeletal or costochondritis
  Reproducible on palpation, worse on movement and twisting, often after recent exertion or coughing. A diagnosis of exclusion - never the first answer in PLAB.
• Gastro-oesophageal reflux
  Retrosternal burning, worse after meals or lying flat, eased by antacids. Common but should not be your top differential until ACS is excluded.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open the consultation

   Set a calm, professional tone before any clinical questions.

   • Wash hands, greet, introduce yourself with name and grade.
   • Confirm the patient's full name and date of birth.
   • Explain you are the doctor seeing them today and you understand they have come in with chest pain.
   • Ask permission to take a history.

2. 2. SOCRATES the pain

   Every letter is a mark. Do not skip any dimension.

   • Site - ask them to point to where it hurts.
   • Onset - sudden or gradual, what they were doing when it started.
   • Character - crushing, squeezing, sharp, tearing, burning?
   • Radiation - jaw, left arm, back. Tearing to the back must trigger dissection on your differential.
   • Associated symptoms - sweating, breathlessness, nausea, vomiting, palpitations, lightheadedness, syncope.
   • Time course - continuous or intermittent, total duration, current state (better, worse, the same).
   • Exacerbating and relieving factors - movement, deep breaths, food, GTN spray, position.
   • Severity - 1 to 10 now and at its worst.

3. 3. Sweep cardiovascular risk factors

   A clean risk-factor pass is one of the highest-yield blocks of marks in this station.

   • Smoking - amount and duration in pack-years.
   • Diabetes, hypertension and high cholesterol - diagnosed or screened.
   • Family history - first-degree relative with heart attack or stroke under 55 in men or 65 in women is high-yield.
   • Diet, exercise, alcohol intake.
   • Recreational drug use - cocaine, in particular, in a young patient with chest pain.

4. 4. Complete the history

   Round out past medical, drug and allergy history before moving to examination.

   • Past medical history - previous chest pain, MI, angina, PE, surgery, hospitalisation.
   • Medications - prescribed, over-the-counter, herbal, supplements.
   • Allergies - especially aspirin and contrast.
   • Brief social history if you have not already covered it in risk factors - occupation, living situation, who is at home, recent travel.

5. 5. Ideas, concerns and expectations

   One short question that earns interpersonal-skills marks and often discloses what the patient is most afraid of.

   • "Is there anything in particular you were worried this might be?"
   • Listen, acknowledge, do not dismiss.

6. 6. Request examination findings

   Tell the examiner what you would examine - the panel will show the findings the station carries.

   • Vital signs - blood pressure (both arms if dissection is on the differential), heart rate and rhythm, respiratory rate, temperature, oxygen saturation.
   • General inspection - colour, distress, peripheral signs of cardiovascular disease.
   • Cardiovascular examination - heart sounds, added sounds, pulses.
   • Respiratory examination - air entry, added sounds, chest expansion.
   • Calves and lower limbs - swelling or asymmetry if PE is on the differential.

7. 7. Request investigations

   ECG is the safety-critical investigation. Skip it and the station collapses regardless of how well the rest goes.

   • ECG within 10 minutes of arrival.
   • Troponin on arrival, repeated at three to six hours per local protocol.
   • Routine bloods - FBC, U&Es, CRP, glucose, lipid profile.
   • Chest X-ray - to rule out pneumothorax, pneumonia, widened mediastinum.
   • D-dimer only if PE is a real differential and the Wells score is low.

8. 8. Explain your working diagnosis in plain English

   Use words the patient can understand. Avoid the words "heart attack" until you have softened the ground.

   • Name the worry first: "Given your symptoms and the family history, the priority for us is to rule out a problem with the blood supply to the heart."
   • Mention one or two alternatives so the patient knows you have considered them.
   • Pause, check understanding before moving on.

9. 9. Outline immediate management

   This is the clinical-management block - cover admission, monitoring, drug treatment and the long-term plan.

   • Admit for observation and serial troponins. Do not send home.
   • Pain relief, oxygen if saturations are low.
   • Aspirin 300 mg if ACS is suspected and no contraindication - explain it thins the blood and reduces clot formation.
   • Glyceryl trinitrate sublingually for pain.
   • Refer to cardiology for ongoing care and possible angiography per local protocol.
   • Secondary prevention if ACS is confirmed - statin, beta-blocker, ACE inhibitor.
   • Smoking cessation, diet and exercise counselling - even one sentence each scores marks.

10. 10. Safety net and close

    Safety-netting is the second of the two safety-critical items. Be explicit.

    • Tell the patient to alert staff immediately if the pain returns or worsens.
    • Confirm they understand they are staying in for observation, not going home.
    • Ask if they have any final questions, thank them, close.

Common pitfalls

• Forgetting to ask about family history of premature heart attack or stroke - it is heavily weighted.
• Not asking about radiation to the jaw or left arm specifically - vague "does it go anywhere?" leaves a mark on the table.
• Agreeing to discharge the patient home before serial troponin - this is the single most common safety-critical fail.
• Skipping the ECG mention because you assumed it was already done. State it out loud.
• Forgetting to counsel smoking cessation - it is a graded interpersonal item even when the diagnosis turns out to be musculoskeletal.
• Using jargon ("ACS", "MI", "thrombolysis") without explanation. Translate every term.
• Closing without checking the patient's understanding at least once.

Frequently asked questions