St Emlyn’s Lesson Plans
Assessing chest pain
Use an aortic presentation and a postoperative PE concern to practise a broad differential and selective investigation.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will compare possible aortic disease with postoperative PE, choosing investigations and explaining what each result would change.
For facilitators
Send: the learner preparation link before teaching.
Bring: Two pathway summaries and a blank ‘question/test/next step’ grid.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.
Core preparation
NICE NG158 suspected PE pathway · About 5 minutes
Read 1.1.16–1.1.18 and 1.1.21, including the two-level Wells table. Focus on the entry conditions for PERC, the effect of recent surgery on assessment, and what happens in the PE-likely branch.
https://www.nice.org.uk/guidance/ng158/chapter/recommendations
RCEM/RCR aortic dissection 2026 · About 5 minutes
Read the summary on printed page 2 and the high-risk features in table 1 on page 7. Then read the D-dimer paragraph on page 5. Focus on why the choice of test depends on the suspected diagnosis.
https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf
Think about (allow 2 minutes): What serious diagnosis would remain possible after a normal ECG in someone with abrupt chest pain radiating to the back?
Picture the scene
Early in your placement, you are asked to assess sudden chest pain. Before ordering ‘chest pain bloods’, decide which time-critical diagnoses fit the presentation.
By the end of the session
- Identify immediate physiological danger and seek senior help.
- Choose investigations that answer a specific clinical question.
- Explain why a PE or ACS rule-out pathway does not exclude every dangerous cause of chest pain.
After the session
- Before your next supervised test request, write the specific diagnosis it addresses and the action you will take for either result.
Optional further learning
You do not need to complete this before attending. The listening time is additional to the core preparation above.
Optional listening · 19 min 30 sec
St Emlyn’s Podcast: Ep 299 - Which patients with chest pain need a troponin?
Explore how symptoms and clinical judgement influence the decision to request troponin.
Search for this episode by title in MedPod Learn if you want to record your listening there.
Identify one apparently reassuring feature that cannot safely exclude MI. Explain how a credible alternative diagnosis changes your assessment. The numerical estimates concern selected suspected-ACS populations; use the current local ECG/troponin pathway. If you have heard this episode before, bring your previous reflection.
https://www.stemlynspodcast.org/e/ep-299-which-patients-with-chest-pain-need-a-troponin/
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Bring local chest-pain, PE and aortic pathways and identify how imaging is requested.
- Check who reviews urgent ECGs and who makes interim anticoagulation decisions when imaging is delayed.
Equipment: Two pathway summaries and a blank ‘question/test/next step’ grid.
Setup: Pairs propose one investigation and must explain both possible next steps before the other pair accepts it.
If the preparation has not been completed
Replace the five-minute “Establish the essentials” slot. Display the NICE two-level Wells table and the RCEM/RCR high-risk aortic features. Give pairs two minutes to identify the concerning details in the two case openings, two to choose the relevant pathway, and one to state what question the proposed investigation must answer.
Suggested session plan
- 0–5 min — Explore. Ask which serious diagnosis needs urgent assessment in each presentation.
- 5–10 min — Establish the essentials. Compare the entry conditions of the two pathways.
- 10–32 min — Discuss & Apply. Use 11 minutes per case, including a brief escalation call and patient explanation.
- 32–40 min — Consolidate. Ask pairs to explain why the cases follow different pathways and give a patient explanation after a negative investigation.
- 40–45 min — Reflect & Transfer. Ask learners to state the clinical question and both possible next steps before their next supervised test request.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Chest pain through to the back
A 60-year-old has abrupt severe chest pain radiating to the back, with BP 180/100. They are alert and the initial ECG is not diagnostic.
Add this information as the discussion develops:
- They describe transient weakness in one leg.
- A colleague suggests a troponin and a normal chest radiograph will be enough.
Ask the group:
- What changes urgency before a laboratory result?
- Which examination and monitoring are useful while seeking help?
- What diagnostic question must the imaging request answer?
Discussion notes
Points to draw out:
- Abrupt pain plus a perfusion or neurological symptom raises concern for acute aortic syndrome; obtain urgent senior assessment and appropriate monitoring.
- Assess pulses/perfusion and neurological findings alongside ABC. Neither a normal ECG nor radiograph independently excludes dissection.
- Use the local aortic imaging pathway with the senior and radiologist; a routine chest study or a negative D-dimer is not interchangeable with that assessment.
- Keep other causes in view and avoid reflex antithrombotic treatment that ignores a plausible competing diagnosis.
Common misconceptions:
- Treating a normal ECG as a general chest-pain rule-out.
- Requiring a ‘tearing’ descriptor before considering aortic disease.
For a more experienced group: Ask how the clinician coordinates competing ACS and aortic concerns without delaying both pathways.
Breathless after an operation
A 35-year-old develops pleuritic discomfort and breathlessness after surgery. Saturation is 95% on air; they are haemodynamically stable.
Add this information as the discussion develops:
- Further assessment reveals tachycardia and unilateral leg swelling.
- A learner suggests using PERC because the patient is young, or a D-dimer because it is easy to request.
Ask the group:
- Does this presentation meet the context for a PERC-based rule-out?
- What changes when the two-level Wells assessment makes PE likely?
- What if imaging cannot happen immediately?
Discussion notes
Points to draw out:
- PERC is considered only when overall clinical suspicion is low and alternatives are feasible; age alone does not establish that context, and recent surgery is relevant.
- Use the validated Wells pathway. A PE-likely assessment proceeds to imaging rather than relying on D-dimer to exclude it.
- Discuss appropriate imaging and any interim anticoagulation with the responsible clinician, considering postoperative bleeding risk and contraindications.
- If PE is excluded, continue to explain the symptoms and assess alternative diagnoses; avoid saying that nothing is wrong.
Common misconceptions:
- Assuming PE is too rare under 40 to matter.
- Ordering D-dimer indiscriminately after surgery.
- Using bedside right-heart findings as a stand-alone PE exclusion test.
For a more experienced group: Change the case to pregnancy and ask why this adult non-pregnant guideline cannot simply be copied.
Important clinical points
- PERC is not a general-purpose rule for all patients with chest pain.
- D-dimer cannot safely replace imaging in a PE-likely pathway or independently exclude dissection.
- Other important causes, including pneumothorax, infection, pericardial disease and oesophageal pathology, depend on the clinical context; a ‘top five’ list is not exhaustive.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Explain why the two cases need different pathways.
- State one condition that must be met before using PERC.
- Write a patient explanation after a negative investigation that still acknowledges uncertainty.
Key teaching points:
- Assess physiological danger and the pattern of symptoms before choosing tests.
- Use investigations within the appropriate diagnostic pathway.
- After a negative investigation, explain what it excludes and what remains uncertain.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Several diagnoses can share pain descriptors and test abnormalities. The safe next action may be senior review rather than another indiscriminate blood test.
If the discussion drifts
What question are we asking, and how would either result change management?
For a more experienced group
Compare the risks of unnecessary imaging with the consequences of missing disease in patients at different pre-test probabilities.
A 30-minute version
30 minutes: opening 3, pathways 5, cases 15, consolidation 5, reflection 2.
Evidence and guidance
- NICE NG158 — Suspected PE pathway and restrictions on PERC.https://www.nice.org.uk/guidance/ng158/chapter/recommendations
- RCEM/RCR aortic dissection 2026 — Recognition and appropriate diagnostic strategy.https://rcem.ac.uk/wp-content/uploads/2026/07/RCEM_BP_TAD_June-26-FINAL_COBADGE-1.pdf
- NICE CG95 — ECG and cardiac chest-pain assessment.https://www.nice.org.uk/guidance/cg95/chapter/recommendations
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Chest pain; pulmonary embolism and aortic disease
Students choose and explain investigations in their clinical context.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-18 · Iain Beardsell.