How to run this case
One run: 28 minutes
- Read the door note 1 min
- Encounter with the patient 15 min
- Oral presentation 2 min
- SOAP note 10 min
Three roles
- Candidate reads the door note, runs the encounter, then presents the case and writes the note.
- Patient plays Mr. Hale from the script and reads each exam finding when the candidate performs that maneuver. No medical knowledge is needed.
- Examiner and timer keeps time, calls 5 minutes and 1 minute left, and ticks the checklist as items happen. With two people, the patient does this too.
The candidate sees only the door note. Everything else is for the partner: print the packet or open this page on a second device, and agree on times before you start. The times here are suggestions, so use your program's if you know them.
Working alone, ask each question out loud before you read its answer in the script, and announce each maneuver before you read its finding. You lose the practice of drawing answers out of a person, but you keep the order, the timing and the note. Afterward, score yourself with the checklist, then read the model presentation, the annotated note and the debrief.
The clinical content follows the 2021 AHA/ACC chest pain guideline and the 2025 ACC/AHA guideline for acute coronary syndromes.1,2 The case is original and fictional.
Door note
Door note for the candidate
Marcus Hale, 56-year-old man. Urgent care clinic. Chief complaint: chest pressure.
- Temp
- 36.9 °C (98.4 °F)
- Heart rate
- 92/min
- BP
- 152/94 mm Hg (right arm)
- Resp
- 18/min
- SpO2
- 97% on room air
You have 15 minutes.
- Take a focused history.
- Perform a focused physical exam.
- Explain your assessment and plan to the patient.
- Afterward, give a 60 to 90 second oral presentation and write a SOAP note.
This is all the candidate sees before the encounter. Use the minute to read it twice and plan. For any chest pain, write down the life-threatening causes you will have to address before you leave the room: acute coronary syndrome, aortic dissection and pulmonary embolism first, then pneumothorax, tamponade and esophageal rupture where the story fits.
Then decide what you will do early. Some actions cannot wait until the history is finished, and the examiner will be watching for them. Plan how you will explain your thinking to the patient in plain words.
Candidate: stop here. Everything below is for the patient and the examiner, including the answers. Come back to it after you have run the case.
Patient script
For the person playing Mr. Hale. Read it through once before the encounter, answer only what the candidate asks, and stay in character until the examiner calls time.
Show the patient script
Patient script for the partner
You are Marcus Hale, a 56-year-old accountant. You are worried but trying to play it down, and now and then you rub the center of your chest. Answer in plain words. If a question is vague, give a short answer and wait.
Opening statement
I've been getting this pressure in my chest for a few days. My wife made me come in.
If the candidate asks an open question such as "Tell me more," add: "It came back this morning at breakfast and didn't go away for a while. That scared me a little." Say nothing else unless asked.
The history, only if asked
- Onset
- Three days ago, walking up the stairs from the parking garage at work.
- Location
- Right here, in the middle of my chest. (Lay a flat hand over the breastbone.)
- Duration
- The first few times, about 5 minutes. This morning, about 20 minutes. There's still a little pressure now.
- Character
- Like a heavy weight, or a tight band. Not sharp. Not tearing.
- What makes it worse
- Stairs, or walking fast. This morning it started while I was sitting at breakfast.
- What makes it better
- Resting, the first few times. I took two antacid tablets yesterday and they didn't do anything.
- Radiation
- Into my left arm, and once into my jaw. Not to my back.
- Timing
- Four or five times in 3 days. They've been coming on more easily.
- Severity
- This morning, 7 out of 10. Right now, about 2.
Other symptoms, only if asked
- Sweating or nausea
- This morning I broke out in a sweat and felt sick to my stomach. I didn't throw up.
- Breathing
- A little short of breath during the spells. Fine in between.
- Lightheaded or fainting
- A bit lightheaded this morning. I didn't pass out.
- Palpitations
- No.
- Pain with a deep breath, lying down or pressing
- No. Breathing in doesn't change it, and neither does lying down.
- Cough, fever or a recent cold
- No.
- Leg swelling, travel, surgery or a past clot
- No to all of those.
- Heartburn
- I get heartburn after spicy food sometimes. This doesn't feel like that.
- Recent activity or injury
- I helped my son move a couch on Saturday, four days ago. My back was sore the next day, not my chest. Could I have pulled something?
Background, only if asked
- Medical history
- High blood pressure for about 8 years. High cholesterol. My last sugar test was borderline. No heart problems that I know of, and I've never had a stress test.
- Surgery
- A knee scope 10 years ago.
- Medicines
- Lisinopril, 20 mg once a day, but I miss it a couple of times a week. I was on atorvastatin and stopped it 6 months ago because my legs ached. Antacid tablets when I need them.
- Allergies and bleeding
- No allergies. No ulcers, bleeding problems or black stools.
- Family history
- My dad had a heart attack at 52 and died of another one at 61. My mom has diabetes.
- Smoking
- About a pack a day since I was 26.
- Alcohol and drugs
- Two or three beers on the weekend. No drugs. Never cocaine.
- Work and home
- I'm an accountant, and work has been stressful. I live with my wife.
Your question for the candidate
When the candidate starts explaining the plan, ask: "Could this just be heartburn? I have a big meeting this afternoon. Can I go to the hospital after that, and drive myself?"
If the candidate explains clearly why you need an ambulance now, agree to it. If they let you drive or wait, say "Great, thanks" and nothing more; the examiner will note it.
Physical exam findings
For the patient or the examiner. Read a finding only when the candidate performs the maneuver or clearly names it. Anything not listed is normal. Hand over the ECG result only when the candidate asks for an ECG.
Show the exam findings
Exam findings read each one only when it is examined
- General
- Anxious, sitting upright, rubbing his chest now and then. Skin warm and dry. Speaks in full sentences.
- Blood pressure, both arms
- Right 152/94 mm Hg. Left 148/92 mm Hg.
- Neck
- No jugular venous distention. No carotid bruits.
- Heart
- Regular rate and rhythm. Normal S1 and S2. No murmur, rub or gallop.
- Lungs
- Clear in all fields. No crackles or wheezes.
- Chest wall
- No tenderness over the sternum, ribs or costochondral joints. Pressing does not reproduce the pressure.
- Abdomen
- Soft and nontender, including the epigastrium. No pulsatile mass.
- Pulses
- Radial and dorsalis pedis pulses 2+ and equal on both sides.
- Legs
- No edema. Calves soft, nontender and equal in size.
- Skin
- No rash on the chest or back.
Tests, only if the candidate asks
- 12-lead ECG
- Sinus rhythm at 90/min. Normal axis and intervals. No ST elevation. T-wave flattening in V5 and V6. No prior ECG for comparison.
- Repeat ECG
- Unchanged.
- Troponin, D-dimer or other blood tests
- Not available at this clinic.
Examiner checklist
Score each item done or not done, one point each. The examiner ticks items as they happen, not from memory at the end. A history item counts if the candidate asked it in any wording; an exam item counts only if the candidate performed or clearly named the maneuver.
Three items are marked critical: they are the actions that keep this patient safe. For practice, call a run a pass when the candidate scores at least 24 of 34 and completes every critical action. Programs set their own standards, so use yours when you know it. After scoring, the examiner names two things done well and two to work on.
Examiner checklist tick each item the candidate does
History
- Onset, and what he was doing when it started
- Character: pressure, as opposed to sharp or tearing
- Location and radiation, including to the back
- How long each episode lasts, and this morning's episode
- The pattern over 3 days: more often, with less exertion, now at rest
- Associated symptoms: sweating, nausea, shortness of breath, lightheadedness
- Pain with breathing, position or pressure on the chest
- Clot risk: leg swelling, travel, surgery, a past clot
- Cardiac risk factors: blood pressure, cholesterol, diabetes
- Smoking, enough to estimate pack-years
- Family history of heart disease, with the age
- Medicines (including the stopped statin), allergies and bleeding history
Exam
- Gets a 12-lead ECG acquired and interpreted within 10 minutes of arrival Critical
- Reviews the vital signs
- Checks blood pressure in both arms (without delaying transfer)
- Looks at the neck veins
- Listens to the heart for a murmur, rub or gallop
- Listens to the lungs
- Presses on the chest wall
- Examines the abdomen
- Compares radial and pedal pulses on both sides
- Checks the legs for swelling and calf tenderness
Communication
- Introduces self, confirms the patient's name, cleans hands
- Opens with an open-ended question
- Lets the patient finish the opening statement
- Summarizes the history back to the patient
- Asks what worries the patient
- Uses plain language, without jargon
Closure and counseling
- Explains that the pressure may be coming from the heart and needs testing today
- Recommends the emergency department by ambulance, now Critical
- Answers the request to drive or wait, with the reason for the ambulance
- Gives non-enteric-coated aspirin, chewed, or names a contraindication, after asking about allergy and bleeding Critical
- Explains what happens next: repeat ECGs and blood tests over several hours
- Checks understanding and asks for questions
Score: ______ of 34 Critical actions: ______ of 3 Practice pass: 24 or more, and every critical action
Model oral presentation
Model presentation about 80 seconds aloud
Mr. Hale is a 56-year-old man with hypertension, hyperlipidemia off his statin and a 30 pack-year smoking history who presents with 3 days of exertional chest pressure that occurred at rest this morning.
The pressure is substernal, radiates to the left arm and jaw, and until today came on with stairs and eased with rest within 5 minutes. The episodes have become more frequent. This morning it began at rest and lasted about 20 minutes, with diaphoresis, nausea and mild dyspnea, and 2 out of 10 pressure persists. It is not pleuritic, positional or tearing, and it does not radiate to the back. Antacids did not help. His father had an MI at 52.
He is anxious but not in distress. Blood pressure is 152/94 on the right and 148/92 on the left, heart rate 92, saturation 97 percent. Heart, lung, chest wall and pulse exams are normal. The ECG shows sinus rhythm with T-wave flattening in V5 and V6 and no ST elevation.
My leading diagnosis is non-ST-elevation acute coronary syndrome. Aortic dissection, pulmonary embolism, pericarditis, GERD and musculoskeletal strain are less likely. I have called EMS for transport to the emergency department for serial high-sensitivity troponins and ECGs, and he has chewed 325 mg of aspirin.
A good presentation follows the order of the note and leaves out what does not change the assessment. Open with one sentence that carries the key features: the age, the risk factors that matter, the time course and the change that brought him in. Someone who hears only that sentence should already be thinking of acute coronary syndrome.
Give the history in the order that supports your reasoning: the features that point to ischemia first, then the pertinent negatives that argue against each dangerous alternative. Report the exam as specific findings, including the blood pressure in both arms, and give the ECG with your reading of it, not just "ECG done."
End with a ranked assessment and a plan that says what you did, not what you might do. Practice it against a timer until you can finish in under 90 seconds without notes.
Keep two vocabularies. Diaphoresis, dyspnea and NSTE-ACS belong in the presentation to the examiner; sweating, shortness of breath and "this could be your heart" belong in the room with the patient. If the examiner asks a question afterward, answer with the finding first and the reasoning second.
Annotated model SOAP note
A note the candidate could write in 10 minutes, with what each part is doing beside it. It uses common abbreviations; follow your program's rules.
Model SOAP note with what each part is doing
Chief complaint and history
CC: "Pressure in my chest for a few days."
HPI: 56M with 3 days of intermittent substernal chest pressure, first with stairs and relieved by rest within 5 min; 4 to 5 episodes, more frequent and with less exertion. Today at breakfast began at rest, lasted about 20 min, 7/10, with diaphoresis, nausea, mild dyspnea and lightheadedness; 2/10 pressure persists. Radiates to L arm and once to jaw. No relief with antacids.
What graders look for. The time course is the diagnosis here: exertional pressure that now comes at rest. Graders look for onset, character, radiation, how long each episode lasts, the change over 3 days and the associated symptoms.
Common miss. Writing "chest pain x 3 days" without the crescendo pattern or this morning's 20-minute episode at rest.
Pertinent negatives
No pleuritic or positional pain, no tearing quality, no radiation to the back. No syncope or palpitations. No cough, fever or recent illness. No leg swelling, recent travel, surgery or prior VTE. Moved a couch 4 days ago, back soreness only.
What graders look for. Each negative answers a dangerous alternative: tearing pain and back radiation for dissection, pleuritic pain and leg swelling for pulmonary embolism, positional pain for pericarditis.
Common miss. A long list of negatives that rule out nothing in particular, while the ones that matter are left out.
Background
PMH: HTN (8 yr), hyperlipidemia, borderline glucose. No known CAD. PSH: knee arthroscopy.
Meds: lisinopril 20 mg daily (misses about 2 doses/wk); atorvastatin stopped 6 mo ago (myalgias); calcium carbonate PRN. Allergies: NKDA. No bleeding history.
FH: father MI at 52, died of MI at 61; mother T2DM. SH: 30 pack-years, current smoker; 2 to 3 beers/wk; no cocaine or other drugs. Accountant, lives with wife.
What graders look for. Risk factors go in with numbers: pack-years, the age of his father's MI, the statin he stopped. Allergies and bleeding history matter because aspirin is in your plan.
Common miss. "FH: heart disease" with no age, or no mention that he stopped his statin.
Objective
Vitals: T 36.9 °C, HR 92, BP 152/94 R arm and 148/92 L arm, RR 18, SpO2 97% RA.
General: anxious, upright, rubbing chest; skin warm and dry. Neck: no JVD, no carotid bruits. CV: RRR, normal S1 S2, no murmur, rub or gallop. Lungs: clear bilaterally. Chest wall: nontender; palpation does not reproduce pain. Abd: soft, nontender, no pulsatile mass. Ext: radial and DP pulses 2+ and symmetric; no edema or calf tenderness.
ECG: sinus rhythm 90, normal axis and intervals, no ST elevation, T-wave flattening V5 and V6; no prior for comparison.
What graders look for. Specific findings, including the ones that argue against alternatives: both arm pressures, the pulses, no rub, a nontender chest wall. Record the ECG with your reading of it and what it does not show.
Common miss. "CV: normal" with no second arm pressure, or an ECG listed as "ordered" with no result.
Assessment
56M with HTN, hyperlipidemia off statin, 30 pack-years and a father with MI at 52, with 3 days of crescendo exertional chest pressure, now at rest with diaphoresis, and a nondiagnostic ECG. Pain is cardiac in character.
1. Suspected NSTE-ACS (unstable angina vs NSTEMI): leading diagnosis.
2. Aortic dissection: less likely; gradual onset, pressure quality, no back pain, symmetric BP and pulses.
3. Pulmonary embolism: less likely; no pleuritic pain, tachycardia or hypoxemia; no reported prior VTE, recent travel or surgery, or leg swelling. PERC is positive because he is 56, so it cannot rule out PE.
4. Pericarditis: unlikely; not pleuritic or positional, no rub, no diffuse ST elevation (their absence does not exclude it).
5. GERD or musculoskeletal strain: unlikely; exertional pattern, no antacid response, nontender chest wall. To be considered after cardiac causes are excluded.
What graders look for. Open with a summary sentence, then a ranked differential with the evidence for and against each diagnosis. Describe the pain as cardiac, possibly cardiac or noncardiac: the 2021 guideline advises against calling chest pain "atypical."1
Common miss. Diagnoses listed without reasons, or GERD ranked first because the patient suggested it.
Plan
1. EMS called at 0752 for transport to the ED; patient not to drive. ED notified; ECG and note sent with EMS.
2. Aspirin 325 mg chewed at 0748 (no allergy or bleeding history).
3. Repeat ECG if symptoms change or persist while awaiting EMS; patient observed continuously.
4. Counseled: possible heart attack or unstable angina; the ED will repeat ECGs and blood tests over several hours. Explained the reason for an ambulance rather than driving. Patient agrees.
5. After ED care: follow up with PCP for smoking cessation, statin and blood pressure control.
What graders look for. Disposition first, with the mode of transport and the time, then every action taken and what the patient was told. Graders check that the plan fits the assessment: suspected ACS cannot end in "follow up in 1 week."
Common miss. Ordering a troponin or a stress test from the clinic and sending him home to wait. For suspected ACS seen in an office, the guideline says delayed transfer for testing should be avoided.1
Debrief: ranking the differential
The differential, ranked
-
Acute coronary syndrome (NSTE-ACS) Most likely; life-threatening
For: Exertional pressure, now at rest, with sweating and nausea; arm and jaw radiation; smoking, hypertension, untreated cholesterol, father with MI at 52.
Against: Nothing that excludes it. A normal exam is common in uncomplicated ACS.
-
Aortic dissection Dangerous; address it
For: Hypertension, smoking.
Against: Gradual onset, pressure rather than ripping pain, no back pain, equal pressures and pulses.
-
Pulmonary embolism Dangerous; address it
For: Shortness of breath during episodes.
Against: Not pleuritic, heart rate 92, SpO2 97%, no clot risk factors. His age keeps PERC from applying.
-
Pericarditis Less likely
For: None strong.
Against: Not sharp, pleuritic or worse lying flat; no rub; no diffuse ST elevation.
-
GERD Less likely
For: History of heartburn.
Against: Exertional; not like his usual heartburn after spicy food; no response to antacids.
-
Musculoskeletal strain Less likely
For: Moved a couch on Saturday, four days ago.
Against: Nontender chest wall; brought on by exertion, not by movement or position.
Rank a chest pain differential on two scales at once: how likely each diagnosis is, and how much harm a miss would do. In this case ACS tops both lists, though dissection and pulmonary embolism, less likely here, would also be dangerous to miss. Mr. Hale's pressure has the features the 2021 AHA/ACC guideline describes as anginal: retrosternal pressure or heaviness that builds over a few minutes and is brought on by exertion. Anginal symptoms that occur at rest or with minimal exertion usually indicate acute coronary syndrome.1 Add the sweating and nausea, the radiation to the arm and jaw and four risk factors, and ACS is the most likely diagnosis and a potentially life-threatening one.
Why "suspected NSTE-ACS" and not a more specific name? Unstable angina is ischemia without myonecrosis detected by troponin, while NSTEMI is acute myocardial injury caused by ischemia, shown by a rise or fall in troponin.2 Without serial troponin results, the two cannot be told apart in this clinic. The first ECG does not show a STEMI, but an evolving or posterior STEMI is still possible, which is why serial ECGs continue while he waits. The label you can defend is the one to write.
The other dangerous causes still need a sentence each, backed by the history and exam. Sudden ripping pain radiating to the back suggests an acute aortic syndrome, and a pulse differential is found in about 30 percent of patients with dissection, so equal pulses lower suspicion without excluding it. Sharp pain that worsens with inspiration and lying supine points to pericarditis.1 For pulmonary embolism, the PERC rule cannot help: it applies only when clinical suspicion is already low, and Mr. Hale fails its first criterion, age under 50.3 GERD and chest wall pain are diagnoses to reach after cardiac causes have been addressed, not before.
The red flags in this case: a crescendo pattern that has progressed to pain at rest, an episode lasting 20 minutes, sweating, pressure that has not fully resolved and a heavy risk profile. Together they take this patient out of any clinic workup and into the emergency department.
Debrief: why an ambulance, today
Common mistakes on this case
- Asking for the ECG at the end of the encounter, or not at all.
- Accepting the patient's theory, heartburn or the couch, because he offered it.
- Skipping the second arm pressure and the pulses, and never asking about tearing pain or back radiation, so dissection goes unaddressed. Equal pressures lower suspicion; they do not exclude it.
- Treating a nondiagnostic ECG as reassurance.
- Ordering a troponin in the clinic and waiting for the result.
- Letting him drive himself, or go after his meeting.
- Calling the pain "atypical" rather than cardiac, possibly cardiac or noncardiac.
- Never answering his question.
The guideline is direct about this setting. Every patient with acute chest pain should have an ECG acquired and reviewed for STEMI within 10 minutes of arrival. Patients seen in an office with clinical evidence of ACS should be transported urgently to the emergency department, ideally by EMS, and for suspected ACS, delaying that transfer to obtain troponin or other tests in the office should be avoided.1 An urgent care clinic that cannot run serial troponins is in the same position.
A nondiagnostic ECG does not change the plan. Myocardial injury is detected or excluded with serial troponin measurements, and the guideline names high-sensitivity troponin as the preferred biomarker. When the first ECG is nondiagnostic, serial ECGs are recommended, especially when suspicion is high or symptoms persist.1 Neither can be finished in this clinic.
Why an ambulance rather than his own car: EMS can monitor him and treat arrhythmias or cardiac arrest on the way, which a private vehicle cannot.2 While he waits, give aspirin if he has no allergy or bleeding contraindication. The 2025 ACS guideline recommends a loading dose of 162 to 325 mg as soon as possible on presentation in ACS, chewed when possible for a faster effect.2
Then say it plainly: "Your symptoms could be coming from your heart, and the tests that can tell us take several hours in an emergency department. The safest way there is an ambulance, because the crew can treat you if your heart rhythm changes on the way." Answer the meeting and the drive directly, and check that he agrees.
