Man Concerned About Chest Pain During Exercise — Free SCA Practice Case
Man concerned about chest pain during exercise
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Mark Henderson
Age
52 years
Consultation Type
VideoAge
52
Situation
Video Consultation.
Reason for Encounter
"Getting chest pain when exercising at the gym. Worried it's his heart."
Medical Records
- ●PMH: Hypertension (diagnosed 4 years ago), Hypercholesterolaemia, Obesity (BMI 32).
- ●Medications: Ramipril 10mg OD, Atorvastatin 20mg OD.
- ●Social: HGV Driver (Long haul). Smoker (15/day).
- ●Family History: Father died of MI aged 58.
Recent Notes
- ●6 Months Ago: BP check 145/88. Advised on lifestyle/weight loss. Joined a gym recently to "sort himself out."
Patient Script
For the friend playing the patient role
Character Overview: You are Mark. You are a "down to Earth" courier driver. You are generally stoic but secretly terrified because your father died young of a heart attack. You have finally tried to get fit, but now your body feels like it's failing you. You are acutely aware that a heart diagnosis could affect your ability to work and drive.
Opening Sentence: "Hi Doctor. Look, I've finally taken your advice and joined a gym. I've been going for a couple of weeks, but every time I get on the treadmill, I get this tight pain in the middle of my chest. It's probably just a pulled muscle, but with my Dad's history, I thought I'd better check."
History if Asked (Data Gathering Phase)
- ●The Pain (SOCRATES):
- ●Site: Central, behind the breastbone.
- ●Character: "Like a heavy band," "tightness," or "squeezing." NOT sharp or stabbing.
- ●Radiation: Sometimes feels a dull ache in the left jaw.
- ●Onset/Precipitating: Happens reliably after 5-10 minutes of brisk walking or jogging.
- ●Relief: Goes away completely within 2-3 minutes if you stop and stand still.
- ●Severity: 6/10.
- ●Red Flags (Unstable Angina/MI):
- ●Rest: NEVER happens when sitting, watching TV, or driving.
- ●Autonomic: You get a bit sweaty and breathless when it happens. No nausea or fainting.
- ●The Hidden Barrier (DVLA/Livelihood):
- ●You are a self-employed courier driver. You drive a van for work every day. You are terrified the doctor will tell you to stop driving, because without driving you have no income. You have a mortgage and no savings.
ICE — Ideas, Concerns, Expectations
Actor guidance: Do not volunteer any of the following unprompted. These responses surface only when the candidate directly explores your perspective.
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Ideas: You've been telling yourself it's probably a pulled muscle from the treadmill — you're not used to exercise and you assumed your body is just complaining. But deep down, you know it feels different from a muscle strain. It reminds you of how your Dad used to describe his chest before he died. You haven't said that out loud to anyone.
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Concerns: Your biggest fear is that this is the same thing that killed your Dad at 58 — and you're only six years younger than he was. You're also terrified that if the doctor puts a label on it, you won't be able to drive for work, and that's the end of everything — the mortgage, the bills, all of it. You'd rather not know than lose your livelihood.
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Expectations: You're hoping the doctor will say it's nothing serious — maybe just unfitness or a muscular thing — and that you can carry on as normal. If it is something, you want to know there's a tablet you can take and still keep driving. You want reassurance, but you also want honesty.
If Asked — Medical History and Medications
Actor guidance: Respond naturally if the candidate asks about your medical history or current medications. Do not volunteer this information unprompted.
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Hypertension / Blood pressure: "Yeah, they told me my blood pressure was high about four years ago. I take the Ramipril for it every morning — I'm pretty good with it, don't miss many. Last time the nurse checked it was still a bit on the high side though."
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Ramipril 10mg: "I take it every morning with my coffee. I've been on it a few years now. No problems with it really — no cough or anything like that."
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Atorvastatin 20mg: "That's the cholesterol one, right? Yeah, I take that at night. I was told my cholesterol was too high a while back. To be honest I've not really changed what I eat — the tablet was easier than giving up bacon sarnies."
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Cholesterol levels: "I don't know the exact numbers. The nurse mentioned it was still a bit high at my last check, but nobody seemed too worried about it."
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Obesity / Weight: "I know I'm overweight — that's partly why I joined the gym. I've been the same sort of size for years. The job doesn't help — you're sat in a cab all day and you eat whatever you can grab at the services."
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Smoking: "Yeah, I still smoke. About 15 a day, sometimes more on a long run. I've been smoking since I was about 18. I know I should stop, especially now, but it's the only break I get on the road."
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Family history (father): "My Dad had a heart attack at 58 — dropped dead at work. No warning, or at least that's what Mum said. He smoked too, heavier than me. That's what's been playing on my mind with all this."
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Recent GP visit (6 months ago): "Yeah, I saw the doctor about six months ago for a blood pressure check. They said I should lose some weight and get more active — that's when I decided to join the gym. Bit ironic really."
Social History and Lifestyle Impact
Actor guidance: This information can be shared naturally in conversation, particularly when discussing how the condition affects your daily life.
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Occupation and daily life: You are a self-employed courier driver. You drive a van delivering parcels across the region, starting early and finishing late. You spend most of the day in the van and eat on the go — whatever's quick and cheap. You live alone since your divorce three years ago. Your two kids are teenagers and live with their mum.
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Lifestyle impact of the condition: "I only get it at the gym, so I suppose I could just stop going — but that defeats the whole point. The thing that's really getting to me is the worry. I can't stop thinking about it on the road. Every time I get a twinge or feel a bit tired, I'm wondering if today's the day. I nearly pulled over on the M62 last week because I'd convinced myself something was happening — turns out it was just indigestion from a dodgy pasty. But that's what it's doing to my head. And if I have to stop driving while they do tests, I don't know how I'll pay the mortgage. There's no sick pay when you're agency."
If Asked — Associated Symptoms
Actor guidance: Respond only if the candidate directly asks about these symptoms. Keep answers brief and natural.
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If asked about palpitations or irregular heartbeat: "No, I've not noticed my heart racing or skipping or anything like that. It's more the tightness."
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If asked about ankle swelling: "No, my ankles are fine. No swelling."
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If asked about breathlessness at rest or lying flat: "No, I'm fine when I'm sitting or lying down. I only get a bit puffed when I'm on the treadmill — but I'm unfit, so I'd expect that."
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If asked about waking up at night breathless (PND): "No, nothing like that. I sleep alright — well, as much as anyone does."
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If asked about dizziness or fainting: "No, I've never fainted or felt like I was going to pass out."
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If asked about calf pain or swelling: "No, my legs are fine. No pain or swelling in the calves."
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If asked about cough or blood in sputum: "I've got a bit of a smoker's cough in the mornings, but nothing new and I've never coughed up blood."
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If asked about fever or recent illness: "No, I've been well otherwise. No infections or anything."
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If asked about weight loss: "No, if anything I've put a bit on. I wish I was losing weight."
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If asked about indigestion or reflux: "I get a bit of heartburn now and again after a greasy meal, but this chest thing feels completely different — it's higher up, and it's the tightness, not a burning."
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If asked about alcohol intake: "I'll have a few pints at the weekend — maybe four or five on a Saturday. Nothing during the week because of the driving."
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If asked about recreational drugs or cocaine use: "No, never touched anything like that. I'd lose my licence."
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If asked about stress or anxiety: "I mean, yeah — the divorce, the money, worrying about this. I wouldn't say I'm depressed, but I'm not exactly relaxed either. But this chest pain isn't anxiety — it only happens when I'm pushing it on the treadmill."
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If asked about exercise tolerance beyond the gym: "I can walk around the shops or up a flight of stairs without any bother. It's only when I'm properly exerting myself on the treadmill that I get it."
Responses to Management (The Negotiation Phase)
- ●If the Doctor suspects Angina:
- ●Reaction: "Angina? That's what old men get. Are you sure? Can't I just take a tablet and carry on?"
- ●If the Doctor discusses Driving:
- ●Reaction: Defensive/Pleas. "You can't stop me driving, Doctor. If I don't drive, I don't get paid. I feel absolutely fine behind the wheel — it only hurts on the treadmill. Can't we just wait until the tests come back before making any decisions?"
- ●If the Doctor prescribes GTN Spray:
- ●Reaction: "Is that the spray under the tongue? Will it make me dizzy? Can I drive after using it?"
- ●If the Doctor refers to Rapid Access Chest Pain Clinic (RACPC):
- ●Reaction: "How long is the wait? Two weeks? So I have to sit at home for two weeks earning nothing? There must be another way."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising Stable Angina
- ●Classic features: Central, constricting or band-like chest tightness — sometimes radiating to the jaw or left arm — reliably provoked by exertion and completely relieved by rest within 2–3 minutes. This pattern is highly characteristic and should prompt urgent action.
- ●Differentiating from musculoskeletal pain: Musculoskeletal pain is typically sharp, positional, or reproducible on palpation. Mark's pain is neither — it is consistently exertional, non-positional, and accompanied by diaphoresis and mild breathlessness.
- ●Differentiating from GORD: Mark distinguishes the tightness from his usual heartburn — different location, character, and triggers. Do not conflate two co-existing but distinct symptoms.
- ●Excluding unstable angina: The critical safety question is whether pain occurs at rest, at night, or with increasing frequency (crescendo pattern). Mark's symptoms are entirely exertional and stable — but this must be actively asked, not assumed.
Investigations: The RACPC Pathway
- ●Per NICE NG185 (Chest pain of recent onset), all patients with suspected stable angina should be referred urgently to a Rapid Access Chest Pain Clinic (RACPC) — typically seen within 2 weeks.
- ●First-line investigation is CT Coronary Angiography (CTCA), which has largely replaced exercise ECG in the initial assessment of stable chest pain. Functional testing (e.g. myocardial perfusion imaging, stress echo) is used where CTCA is inconclusive or for functional significance of identified stenoses.
- ●Do not arrange an exercise ECG in primary care as a substitute for RACPC referral — this is not the recommended pathway.
Immediate Management in Primary Care
- ●GTN spray (glyceryl trinitrate): Prescribe 400 micrograms sublingually PRN. Instruct the patient to sit down before use (risk of hypotension and dizziness), use one spray when pain starts, repeat after 5 minutes if needed, and call 999 if pain persists after two doses or 15 minutes. Do not drive after use.
- ●Defer further pharmacotherapy until RACPC: First-line anti-anginal therapy (a beta-blocker such as bisoprolol or a calcium channel blocker such as amlodipine — per NICE NG185) and antiplatelet therapy (aspirin 75mg OD) are core components of confirmed stable angina management. With rapid specialist access available, these should be initiated following RACPC assessment and confirmation of the diagnosis rather than empirically in primary care. Document the proposed plan so it can be acted on at the post-RACPC review.
Cardiovascular Risk Factor Optimisation
- ●Suboptimal lipid control: Mark is on atorvastatin 20mg with cholesterol still above target and an unchanged diet. Per NICE NG238 (Cardiovascular disease: risk assessment and reduction), patients with established or suspected coronary artery disease should be on high-intensity statin therapy — atorvastatin 40–80mg. Recognise this gap and document the plan to uptitrate following RACPC review.
- ●Suboptimal BP control: His most recent BP was 145/88 despite ramipril 10mg (maximum dose). This is above the treatment target for a patient with his risk profile. Adding a second agent — for example amlodipine, which would also have anti-anginal benefit — is a logical option to discuss at the post-RACPC review.
- ●Smoking cessation: Smoking is the single most important modifiable cardiovascular risk factor. A brief conversation is not sufficient — offer nicotine replacement therapy (NRT), varenicline (Champix), or referral to a stop smoking service. Frame it as the most powerful thing he can do right now.
- ●Weight and diet: Acknowledge the structural barriers (long days on the road, eating on the go, limited time for cooking) and offer practical rather than generic advice. Reducing saturated fat and caloric density — even small changes — has meaningful cardiovascular benefit.
Exercise Guidance
- ●Do not advise Mark to stop exercising. Graded physical activity is beneficial for cardiovascular health and central to his long-term management.
- ●Advise him to modify rather than stop — walk at a comfortable pace rather than running, avoid pushing through pain, and stop immediately if tightness develops.
- ●Frame the gym decision positively: his decision to get fit unmasked a treatable condition early. This is a good outcome, not a reason to feel the gym was a mistake.
DVLA and Driving Advice — Group 1 Licence
- ●Mark holds a standard Group 1 (car/van) licence. He does not need to notify the DVLA about angina, and there is no legal obligation to stop driving. However, he should be clearly advised not to drive if symptoms occur at rest, while driving, or with emotion, as this would require him to stop until symptoms are under control. His current symptoms occur only on high exertion away from the vehicle, so there is no immediate restriction, but this must be clearly explained and safety-netted. Do not overstate the legal position — telling him he must stop driving entirely would be inaccurate and unnecessarily harmful to his livelihood and wellbeing.
Safety Netting — When to Call 999
- ●Unstable angina / ACS: If chest pain occurs at rest, wakes him at night, lasts more than 15–20 minutes despite GTN, or becomes more frequent or occurs with less exertion than previously — call 999 immediately.
- ●After GTN use: If two doses of GTN (10 minutes apart) do not relieve the pain, this is a 999 emergency.
- ●Do not advise the patient to drive himself to hospital if pain occurs while not in an emergency setting — arrange transport or call emergency services.
Common Candidate Mistakes in This Case
- ●Premature medication initiation: This is a first presentation of suspected stable angina in primary care. The correct next step is RACPC referral. Initiating aspirin, uptitrating the statin, starting a beta-blocker or calcium channel blocker, or adding antihypertensives before specialist assessment and confirmation is premature. Candidates should acknowledge these will be reviewed following RACPC, not initiate them during this consultation.
- ●Forgetting GTN spray: RACPC typically has a two-week wait. Sending the patient away with no immediate symptom relief is a practical and safety-relevant oversight. GTN spray with clear instructions is the one medication that should be initiated at this appointment.
- ●Anchoring on the musculoskeletal diagnosis: Mark opens by suggesting a pulled muscle and several candidates accept this framing without adequately challenging it. The history — central, exertional, relieved by rest, with jaw radiation, in a middle-aged smoker with hypertension and a family history of premature cardiac death — is classical angina until proven otherwise.
- ●Failing to explore and address the hidden concerns: Mark does not volunteer his fear about his father's death or his financial anxiety unprompted. Candidates who focus entirely on the medical management without exploring ICE will miss the most important part of this consultation. Acknowledging the father's story, naming the financial fear, and reframing the gym as a decision that uncovered something treatable early are all high-value interpersonal moves that significantly affect how Mark leaves the room.
- ●Providing vague or absent safety-netting: Telling the patient to "come back if it gets worse" is not adequate. Candidates must specify when to call 999 — rest pain that does not resolve within 15 minutes despite GTN, or symptoms that become more frequent or occur with less exertion.
Further reading
From the PCCS Academy, the Primary Care Cardiovascular Society’s learning modules for primary care.
Free for practising healthcare professionals. You need a PCCS account to open these. Join the PCCS
Mapped to the RCGP curriculum topic: Cardiovascular Health.
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