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Practice case P2-12 · Face-to-face · simulated patient

Chest tightness on the hill

A 58-year-old bus driver has been getting a tight chest walking up the hill to the depot. His wife made him come.

Reviewed and kept current

Station family: History, diagnosis and management · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice. Your supervising GP is available.
Patient	Mr Derek Hughes, 58, bus driver
Reason for appointment	“Chest pain on and off — three weeks.”
Observations (healthcare assistant)	BP 152/92, pulse 78 regular, SpO₂ 98%, BMI 31.
Records	Hypertension — amlodipine 5 mg daily. Smoker. Total cholesterol 6.4 mmol/L three years ago — not followed up. HbA1c 41 mmol/mol (2024). No known allergies.

Your task

•

Take a focused history.

•

Ask for the findings of any examination or bedside test you would do now; they will be read out to you.

•

Explain your working diagnosis and agree a management plan.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Derek Hughes, 58, bus driver for 22 years. Stoical; you play things down. Your wife Pauline made the appointment.
You rub the centre of your chest with a closed fist when you describe the feeling.

Opening line — say this verbatim

“It’s probably nothing, doc. I get a bit of a tight chest when I’m rushing about. The wife’s made me come.”

Volunteer freely if given the space

A tightness across the middle of your chest, like a band or a weight, when you walk up the hill to the depot or carry shopping upstairs.
It goes off when you stop for a couple of minutes. It has been happening for about three weeks.

Only if asked

It sometimes spreads to your left arm and jaw. Cold wind, hills and hurrying after a heavy meal bring it on.
Never at rest, never at night. No episode has lasted more than five minutes. It is not getting more frequent and is not coming on with less effort. The last one was this morning walking in from the car park — gone within two minutes of standing still.
A bit short of breath with it. No sweating, sickness, palpitations or blackouts.
No calf pain or swelling, no coughing blood, no pain on breathing in. No heartburn or acid; bending or lying down makes no difference. Pressing on the chest does not hurt.
Risk factors: 15 cigarettes a day for 40 years; blood pressure tablets; “cholesterol was high once — nobody chased it”; no diabetes. Your father died of a heart attack at 56; your brother had stents at 52.
Little exercise; canteen food; about ten units of alcohol a week.
Tablets: amlodipine. Only if asked about anything else you take, anything bought without prescription, or directly about tablets for erections: sildenafil — “the blue tablets for erections” — bought online, about once a week. You are embarrassed.
It has never happened while you were driving the bus.

Impact on daily life — home and work (only if asked)

You now park closer to avoid the hill, and you have stopped walking football.
You drive a double-decker 40 hours a week. There are four years left on the mortgage.
You have not told your manager. Pauline is worried sick.

Ideas, concerns and expectations

Idea: a pulled muscle, or indigestion.
Concerns (if asked): a heart attack like your dad — “he dropped dead at 56” — and your bus licence: “If it’s my heart, that’s my job gone, isn’t it?” That is why you put off coming.
Expectation: a quick check-over and perhaps some antacids.

Cues to deliver, timed

Minute 2: rubbing your chest — “Dad had the same sort of thing.”
Minute 4: “You won’t have to tell work, will you?”
If a spray under the tongue is offered and nobody has asked about other tablets, say nothing — unless invited to add anything.

If the doctor summarises and asks whether you want to add anything

If sildenafil has not come out: lower your voice — “While we’re at it — I take those blue tablets now and then. Got them online. Does that matter?”
If it has: “Pauline thinks I’m going to drop dead like my dad. Am I?”

How to respond to the doctor

If the doctor explains clearly that this sounds like angina — narrowing of the arteries that supply the heart, not a heart attack — and that you need to be seen in a specialist chest pain clinic within a fortnight, which will arrange a heart scan, a spray, aspirin, and help with smoking, blood pressure and cholesterol: quiet for a moment — “Pauline said it would be this.”
If the bus licence is explained honestly and kindly — that you must stop driving the bus now and tell the DVLA, that the licence can be returned once you are treated, have had no angina for at least six weeks and meet the DVLA’s exercise or functional test requirements, and that you can still drive your car: upset, then practical — “Right. What do I tell my manager?”
If the doctor says you can carry on driving the bus: relieved — and you leave.
If the doctor explains how to use the spray and exactly when to call 999, repeat it back correctly if asked.
If the doctor dismisses it as muscular or indigestion: “That’s what I thought. Thanks, doc.”

Do not

Volunteer the sildenafil, your father’s death or the worry about your licence unless asked or invited to add anything.
Report pain at rest, at night, or lasting more than a few minutes — you have had none.

Findings to give the candidate — only if asked for

If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Looks well and is comfortable at rest. BP 152/92, pulse 78 regular, respiratory rate 14, SpO₂ 98%, afebrile. Heart sounds normal with no murmurs; JVP not raised; chest clear; no chest-wall tenderness; no ankle oedema; calves soft; peripheral pulses present. 12-lead ECG performed now: sinus rhythm 76/min, normal axis, no ST-segment or T-wave changes, no Q waves.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Pain characterised: central tightness, on exertion, relieved by rest within minutes, radiating to arm and jaw — all three features of typical angina Red flags for acute coronary syndrome: pain at rest or at night, over 15 minutes, more frequent or on less effort, sweating, collapse; PE and aortic features Risk factors quantified; all medicines including those bought online — sildenafil; asks for examination and ECG findings ICE (fears a heart attack like his father; fears for his bus licence) and impact — avoiding the hill, walking football, a 40-hour driving week	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then: stable angina — not a heart attack, unstable angina, reflux, muscular or valve pain, and why; a normal ECG does not exclude it Rapid access chest pain clinic within two weeks (CT coronary angiography); bloods; GTN with instructions — not within 24 hours of sildenafil; aspirin 75 mg; supervising GP; smoking and BP Must stop driving the bus and notify the DVLA now; may drive his car unless symptoms at rest, with emotion or at the wheel; fit note Safety-net: pain not gone 5 minutes after a second GTN dose, or pain at rest with sweating or breathlessness → 999; attacks more frequent, on less effort or at night → same-day assessment · Follow-up: GP in 1–2 weeks with bloods; chest pain clinic within 2 weeks	☐	☐	☐	☐	/4
3 · Interpersonal skills Takes “it’s probably nothing” seriously without alarming him Asks about sildenafil without embarrassment Breaks the licence news with empathy; is honest and hopeful about getting it back Responds to the father cue; plain language; asks him to repeat the GTN and 999 instructions	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Characterises the pain: site, character, radiation, precipitants, relief with rest and how quickly, duration, frequency and trend — establishes all three features of typical angina Red flags for an acute coronary syndrome: pain at rest or at night, episodes longer than 15 minutes, increasing frequency or lower threshold, sweating, nausea, syncope; when the last episode was Other causes tested briefly: pleuritic pain, haemoptysis or calf symptoms (pulmonary embolism); tearing pain to the back (dissection); link to meals or posture (reflux); exertional syncope (aortic stenosis) Risk factors quantified: smoking pack-years, hypertension, cholesterol, diabetes, family history; diet, exercise, alcohol Full medication history including over-the-counter and online purchases — elicits sildenafil Asks for examination findings and a 12-lead ECG, and interprets them ICE: thinks it is muscular or indigestion; fears dying like his father and losing his bus licence; expects antacids Impact on daily living: parks closer to avoid the hill, stopped walking football; 40-hour week driving a double-decker; mortgage; has not told his employer	Summarises and checks whether he wants to add anything Working diagnosis with justified differentials: stable angina — a constricting central chest discomfort, brought on by exertion and relieved by rest within minutes (all three features of typical angina), in a 58-year-old smoker with hypertension, raised cholesterol and a strong family history. A heart attack or unstable angina is unlikely — no pain at rest or at night, nothing longer than five minutes, no change in pattern and a normal ECG — but a normal resting ECG does not rule angina out. Acid reflux (no link to meals or posture), a muscular cause (exertional, no tenderness) and aortic stenosis (no murmur) fit less well; anaemia will be checked Urgent referral to the rapid access chest pain clinic, to be seen within two weeks — CT coronary angiography is the usual first test; bloods: full blood count, urea and electrolytes, lipids, HbA1c Symptom relief: GTN spray with instructions — and must not be used within 24 hours of sildenafil; advises stopping the sildenafil until reviewed Secondary prevention: aspirin 75 mg daily; statin and a first-line anti-anginal (beta-blocker, or optimising his calcium-channel blocker) discussed with the supervising GP; blood pressure; stop-smoking support; diet and activity Driving: as a bus (Group 2) driver he must stop driving the bus and notify the DVLA now; relicensing is considered once he has been free of angina for six weeks and meets the DVLA’s exercise-test requirements; he may drive his car unless symptoms occur at rest, with emotion or at the wheel; fit note for amended duties Safety-net: with chest pain: stop and sit, use the GTN spray; if the pain is still there after five minutes take a second dose; if it has not gone five minutes after the second dose → call 999 and do not drive; also 999 for pain at rest with sweating, sickness, breathlessness or collapse; attacks becoming more frequent, coming on with less effort, or at rest or at night → same-day medical assessment. Follow-up: rapid access chest pain clinic within two weeks — he rings the practice if no appointment has arrived within a week; GP review in one to two weeks with the blood results, blood pressure, how he is managing with the spray and his stop-smoking plan; fit note covering bus-driving duties; confirmation that he has notified the DVLA and his employer.	Takes “it’s probably nothing” seriously without frightening him Picks up the father cue and the fear behind the delay in attending Asks about erectile dysfunction tablets matter-of-factly; responds without embarrassment Breaks the news about the bus licence with empathy; is honest and realistic about getting it back; helps him plan what to tell his manager Plain language: “narrowing of the arteries that supply the heart muscle” Asks him to repeat the GTN and 999 instructions; invites Pauline to the next appointment
3	Typical angina established and ACS red flags screened; one of the medication history (sildenafil), the examination / ECG request, the occupational history or ICE missing.	Correct diagnosis with reasoning, urgent referral, GTN with a specific safety-net, and correct driving advice; one of the sildenafil interaction, aspirin / secondary prevention, bloods or the follow-up missing.	Clear and kind; one of the father cue, the licence conversation or the teach-back handled briefly.
2	Pain history adequate but red flags incomplete; risk factors partial; occupation not explored; concerns not elicited.	Angina suspected but managed loosely: routine referral, GTN without instructions, or driving advice vague or limited to the car; no differentials; safety-net generic.	Competent but impersonal; licence advice delivered as a rule with no acknowledgement of what it means to him.
1	Superficial pain history; no red-flag screen; no risk factors. Or unsafe: no relevant history; or accepts “probably nothing” and does not assess.	Treats as indigestion or muscular; or arranges only an “exercise ECG sometime”; no driving advice and no safety-net. Or unsafe: reassures him and sends him back to drive the bus; prescribes GTN to a man taking sildenafil without asking or warning; or reassures him without asking about pain at rest or at night.	Alarming (“you could drop dead”) or dismissive; concerns ignored. Or unsafe: rude, or visibly embarrassed and judgemental about the sildenafil.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Jumps from risk factors to driving to the pain and back; asks for the ECG before taking a history; no summary before the plan.
2 · Issues	Key issues or priorities not recognised	Treats it as a blood-pressure or lifestyle review; does not recognise probable angina in a vocational driver as the priority.
3 · Time	Poor time management	Exhaustive risk-factor and lifestyle history; GTN instructions, the DVLA and the safety-net squeezed out.
4 · Findings	Abnormal findings or results, or their implications, not identified	Told “ECG normal” and concludes the heart is fine; does not connect BP 152/92, cholesterol 6.4 never followed up, and a father dead at 56.
5 · Examination	Physical examination or use of instruments not competent	Does not ask for any examination or ECG; or receives the findings and cannot say what a normal ECG and the absence of a murmur mean here.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“Indigestion” or “a pulled muscle”; or calls it a heart attack; cannot explain why this is stable angina rather than an acute coronary syndrome, reflux or aortic stenosis.
7 · Management	Management plan not reflecting current best practice	Routine cardiology referral; GTN prescribed without asking about sildenafil; no aspirin; spray given with no instructions; tells him he can keep driving the bus, or says nothing about the DVLA; “come back if it gets worse”.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	Delivers “you must stop driving” as a regulation and moves on; no acknowledgement of 22 years in the job or the mortgage.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “Dad had the same sort of thing” and “you won’t have to tell work, will you?”; never gives him the opening to mention the blue tablets.
10 · Language	Language or explanations not understandable; understanding not checked	“Typical angina, three out of three, so I’ll refer you to RACPC for CTCA and start GTN PRN” — and no check that he knows when to call 999.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

NICE CG95 — typical angina has all three of: constricting discomfort in the front of the chest, neck, shoulders, jaw or arms; precipitated by physical exertion; relieved by rest or GTN within about five minutes. Two features = atypical angina; one or none = non-anginal chest pain.
For typical or atypical angina, NICE CG95 recommends CT coronary angiography as the first-line diagnostic test. Do not use an exercise ECG to diagnose or exclude stable angina. A normal resting ECG does not exclude it.
NICE CG95 — suspect an acute coronary syndrome if pain lasts longer than 15 minutes, comes with nausea, vomiting, marked sweating or breathlessness, or with haemodynamic instability, or if angina is new or abruptly worse, frequent and on little or no exertion. If suspected: emergency admission when there is current pain, or pain in the last 12 hours with an abnormal or unavailable ECG; same-day assessment when pain-free with a normal ECG and pain in the last 12 hours, or when the last pain was 12–72 hours ago. Mr Hughes’s brief, exertion-only, unchanged episodes do not meet these criteria — which is why asking when the last episode was matters.
NICE CG126 — while awaiting assessment: a short-acting nitrate for symptoms, with advice on how to use it, its side effects (headache, flushing, dizziness — sit down) and to call an emergency ambulance if the pain has not gone five minutes after a second dose; consider aspirin 75 mg daily; offer a beta-blocker or calcium-channel blocker as first-line anti-anginal; offer a statin.
Nitrates and PDE5 inhibitors must not be combined — risk of profound hypotension. GTN should not be used within 24 hours of sildenafil or vardenafil, or 48 hours of tadalafil. Always ask about medicines bought online.
DVLA — angina. Group 1 (car, motorcycle): no need to notify; must not drive when symptoms occur at rest, with emotion or at the wheel. Group 2 (bus, lorry): must stop driving and must notify the DVLA; may be relicensed when free of angina for at least six weeks, provided the exercise or functional test requirements are met.
If a patient continues to drive when unfit, the GMC expects you to make every reasonable effort to persuade them to stop, and if they do not, to inform the DVLA — telling the patient that you are doing so.
His smoking history is 30 pack-years (15 a day for 40 years). Stopping smoking is the single most effective change he can make; offer behavioural support with pharmacotherapy (NICE NG209).
An F2 would discuss starting aspirin, a statin and an anti-anginal with the supervising GP the same day.

Where candidates lose marks at this station

“Your ECG is normal, so it isn’t your heart.”
GTN without asking about sildenafil.
A spray with no instructions and no 999 rule.
Telling a bus driver he can carry on driving.
A routine referral for a three-week history of angina.
Forgetting why he put off coming.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Cardiovascular
Domain 3 · Clinical and professional capabilities	History, examination and differential diagnosis · Investigations: request, interpret, act · Chronic condition management plans · Safe prescribing · Managing risk
Domain 5 · Patient presentations	Chest pain · Fitness to drive
Domain 6 · Conditions	Ischaemic heart disease (including stable angina) · Acute coronary syndromes
Station family	History, diagnosis and management — History, diagnosis and management

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-12

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-12-exertional-chest-pain

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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