Man Whose Chest Pain Settled An Hour Ago, Planning to Drive Himself to Hospital — Free SCA Practice Case

Character Overview: You are Gordon, a 55-year-old builder. About an hour and a half ago, while lifting heavy materials at work, you developed a heavy, tight central chest pain that spread down your left arm. You went cold and sweaty and felt sick. It lasted about twenty minutes and eased once you stopped and sat down; it settled completely about an hour ago and you feel fine now. Your father died of a heart attack at 61. Your blood pressure has been high on home readings but nothing was ever started. You smoke about fifteen a day. You have decided you should get checked, and you plan to drive yourself to the hospital — you do not want to make a fuss or "waste an ambulance", and you are worried about leaving your van at the site. You are practical and slightly dismissive of your symptoms, but you are not aggressive and you will listen to a clear explanation.

Opening Sentence: "Hello Doctor. I had a bit of a turn about an hour and a half ago — chest pain while I was lifting at work. Went down my arm, came over all sweaty. It's gone now, I feel fine. I thought I'd better get it looked at, so I'm going to drive myself up to A&E in a bit. I just wanted to let you know really."

History if Asked (Data Gathering Phase)

• ●The pain: "Heavy and tight, right in the middle of my chest. It went down my left arm."
• ●Onset and duration: "Came on while I was lifting heavy stuff at work. Lasted about twenty minutes. Eased off when I stopped and sat down."
• ●Associated symptoms: "I went cold and sweaty with it. Felt a bit sick too."
• ●Now: "Completely gone. I feel absolutely fine now — that's why I'm not making a big deal of it."
• ●His plan: "I'll drive myself up. I don't want to waste an ambulance, and I need to move my van anyway."
• ●Family history: "My dad died of a heart attack. He was 61."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

• ●Ideas: Gordon half-believes it was muscular from the lifting, though his father's death makes him uneasy. "Probably pulled something lifting. But… my dad died of his heart at 61, so it's in the back of my mind."
• ●Concerns: He is privately frightened it was his heart, but is playing it down; he is also concerned about not making a fuss, his van, and losing work. "I don't want to be dramatic. And I've got the van and a job to finish."
• ●Expectations: He expects to drive himself to hospital and simply be told that is sensible. "I'm going to drive up. I just wanted to run it past you."

If Asked — ACS and Risk-Factor Screen

The patient answers these only when directly asked.

• ●If asked about the character of the pain (heavy, tight, crushing, band-like): "Heavy and tight, like a weight on my chest."
• ●If asked about radiation (arm, jaw, neck, back): "Down my left arm mainly. A bit into my jaw, now you mention it."
• ●If asked about exertional relationship: "It came on when I was lifting and eased when I stopped."
• ●If asked about autonomic features (sweating, nausea, vomiting, clamminess): "Cold sweat and felt sick, yes."
• ●If asked about breathlessness or palpitations: "A bit breathless with it at the time. No palpitations."
• ●If asked about whether it is truly gone now, or any residual discomfort: "Completely gone. Nothing at all now."
• ●If asked about previous similar episodes: "Now you ask — I've had a couple of milder twinges on the stairs over the last few weeks. Nothing like this though." (Crescendo pattern.)
• ●If asked about pleuritic or positional features, or tenderness on pressing: "It wasn't worse with breathing, and pressing on my chest doesn't reproduce it."
• ●If asked about smoking, alcohol, exercise, weight: "Fifteen a day. Few pints at the weekend. Physical job but no other exercise. Bit overweight."
• ●If asked about blood pressure and cholesterol: "My BP's been high on the home machine a few times. Never sorted it out. Cholesterol never checked."
• ●If asked about diabetes: "Not that I know of."
• ●If asked about medication and allergies: "Nothing at all, and no allergies."
• ●If asked about who is with him and where he is: "I'm at home now. My wife's here."
• ●If asked about whether he has taken anything for it: "No, I haven't taken anything."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains this could be a heart attack or unstable angina: "You think it could actually be my heart? But it's stopped — surely if it was serious it'd still hurt?" (The tested point is explaining that resolution of pain does not exclude acute coronary syndrome.)
• ●If the Doctor says he must call 999 and must not drive — the key negotiation: "An ambulance? Isn't that a bit over the top for something that's stopped? I can be there in fifteen minutes in the van." (The tested point is a firm, clear refusal of the drive-in plan.)
• ●If the Doctor explains why driving is dangerous: "I hadn't thought about it like that — that I could collapse at the wheel and hurt someone else." (The tested point is explaining the specific risk of driving, including to others.)
• ●If the Doctor advises aspirin: "Aspirin? We've got some in the cupboard. Chew it, you say?" (The tested point is advising aspirin 300 mg chewed, having checked for contraindications.)
• ●If the Doctor gives interim safety advice: "So stay put, my wife stays with me, unlock the front door, and if it comes back ring 999 straight away?"
• ●If the Doctor addresses the "wasting an ambulance" worry: "So this is exactly what they're for? Alright. I'll ring them now."