Chest pain OSCE station: history, red flags and next steps

27 October 2026

In short: In a chest pain station, check first whether the pain is happening now or when it last occurred. Then take a structured pain history, ask directly about the features that suggest an acute coronary syndrome, cover cardiovascular risk factors, and keep the life-threatening alternatives in your differential. Close with a clear, honest explanation and a plan.

Key points

Timing comes first: current pain, or pain in the last 12 hours, changes how urgent this is.
NICE lists specific features that may indicate an acute coronary syndrome (ACS). Ask about each one.
Cover risk factors: smoking, diabetes, hypertension, dyslipidaemia, family history and known heart disease.
Keep pulmonary embolism, aortic dissection, pneumothorax and pneumonia in your differential.
Explain the possible causes and the uncertainty to the patient. Don't promise a diagnosis.

Where this sits in the content map

Chest pain is a named presentation in Domain 5 of the GMC's MLA content map, and acute coronary syndromes are a named condition in Domain 6, alongside aortic dissection, pulmonary embolism and pneumothorax. The GMC uses ACS as its own example of how the domains connect: anatomy, interpreting symptoms in context, and a prioritised differential that guides management.

Start with timing

NICE guidance on recent-onset chest pain (CG95) starts here: check immediately whether the person has chest pain now. If they are pain free, find out when the last episode was, particularly if it was in the last 12 hours. In a station, this is your first focused question after the introduction and consent.

Take a structured pain history

Use whatever structure you know well, such as SOCRATES, and let the patient tell it in their own words first:

Site and whether it spreads, for example to the arms, back or jaw
Onset: sudden or gradual, at rest or on exertion
Character: tight, heavy, sharp, burning, tearing
Radiation
Associated symptoms: nausea, vomiting, sweating, breathlessness, palpitations, collapse
Timing: how long each episode lasts and how often it happens
Exacerbating and relieving factors: exertion, rest, breathing, posture, eating
Severity

Then ask about previous episodes, previous heart disease and its treatment, and any earlier investigations for chest pain.

The features NICE says may indicate ACS

NICE CG95 lists symptoms to assess for at the start:

pain in the chest and/or other areas (for example the arms, back or jaw) lasting longer than 15 minutes
chest pain with nausea and vomiting, marked sweating or breathlessness, particularly a combination of these
chest pain with haemodynamic instability
new-onset chest pain, or an abrupt deterioration in previously stable angina, with frequent recurrent pain on little or no exertion, often lasting longer than 15 minutes.

Two further points from the same guidance are worth knowing. Don't assess ACS symptoms differently in men and women, or in different ethnic groups, and not everyone with ACS has central chest pain as the main feature. And don't use the response to glyceryl trinitrate (GTN) to make a diagnosis.

Risk factors and stable chest pain

For stable chest pain, NICE describes anginal pain as:

constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
brought on by physical exertion
relieved by rest or GTN within about 5 minutes.

All three is typical angina, two is atypical angina, and one or none is non-anginal chest pain. Factors that make angina more likely include age, male sex, smoking, diabetes, hypertension, dyslipidaemia, a family history of premature coronary artery disease, other cardiovascular disease and established coronary disease.

Ask about each risk factor directly. A patient who isn't asked about smoking may not mention it.

Keep the dangerous alternatives in view

A cardiac cause isn't the only serious one. NICE mentions pulmonary embolism, aortic dissection, pneumothorax and pneumonia as diagnoses that other tests may be needed to rule out. Ask the questions that point towards them: sudden pleuritic pain and breathlessness, tearing pain through to the back, recent immobility or surgery, cough and fever. Then cover the common causes too, such as musculoskeletal pain and reflux.

Before you finish, give a short summary and a prioritised differential.

Next steps, as NICE describes them

If you are asked what you would do next:

ECG: take a resting 12-lead ECG as soon as possible, without delaying transfer to hospital.
Emergency referral if ACS is suspected and the patient has pain now, or had pain in the last 12 hours with an abnormal or unavailable resting ECG.
Urgent same-day assessment if ACS is suspected, there is no reason for emergency referral, and the patient had pain in the last 12 hours but is now pain free with a normal ECG, or the last episode was 12 to 72 hours ago.

Say what you would do and why. Follow the station task: a history station may only ask for your differential and plan, not a treatment regimen.

Explaining to the patient

NICE asks clinicians to explain the possible causes and the uncertainties, correct any misinformation and discuss the person's concerns, including anxiety when the cause isn't known yet. In a station, that means plain language, one point at a time, a check that they have understood, and a clear safety net: what to do if the pain comes back.

How MedExamHelper fits

MedExamHelper's AI patient is instructed never to volunteer more than the question asks, so if you don't ask about risk factors or associated symptoms, you won't hear about them. Your notes and differential are saved to your transcript, and the marks cite the exact line of the conversation they came from.

Common questions

What should I ask first in a chest pain station? After introducing yourself and gaining consent, find out whether the pain is happening now and, if not, when the last episode was.

Does relief with GTN mean the pain is cardiac? No. NICE says not to use the response to GTN to make a diagnosis.

Do symptoms of ACS differ between men and women? NICE says not to assess ACS symptoms differently in men and women, and notes that not everyone with ACS has central chest pain as the main feature.

What counts as typical angina? NICE defines typical angina as all three of: constricting chest discomfort, brought on by exertion, and relieved by rest or GTN within about 5 minutes.

Which other serious causes should I mention? Pulmonary embolism, aortic dissection, pneumothorax and pneumonia are the ones NICE names in this guidance.