TAYLOR · Angina

Patient Details

Name: Michael / Mary Taylor
Age: 55 years
Opening statement: "I have been having some pain in my chest doctor"

Facilitator Notes

History: clarify pain features and CHD risk factors
Examination: straightforward cardiovascular exam
Management: structured plan, clear explanation of presumptive diagnosis
Behaviour: patient reacts negatively to authoritarian approach — needs flexible, empathic style
Anticipatory care: prioritise key preventive issues for this consultation

Most likely: Angina — central dull/heavy retrosternal pain, exertion-related, relieved by rest. Less likely: muscle strain. Resource: NICE CKS – Chest pain.

Clinical Details

Freely volunteered: Chest pain when carrying/erecting shelving for customers (last 2 months — had to lay off staff so doing their job). Partner made them come; thinks pain is just from strain of lifting.

Only if asked specifically:

Site: Central sternal (flat of hand, middle of chest); does not radiate
Quality: Heavy, dull ache · Intensity: uncomfortable rather than unbearable
Timing: First ~2 months ago with shelving; stops activity → pain goes. Recurs with that job ~1–2×/week. Yesterday after evening meal ran up stairs — pain at top. Always goes in minutes. No medication tried
Associated: Rather sweaty when pain comes on (puts down to weather + exertion)

After sensitive questioning: Thinks muscle strain. Partner worried it might be heart (mentioned last night). Patient dismissive — “I’ve always been very fit.” Played squash regularly; no time this year due to work.

Patient Perspective (ICE)

Ideas: Pain from heavy lifting and running around more.

Concerns: Partner worried it’s the heart (patient dismissive). Worried about lots of tests / hospital — no time because of work.

Expectations: Doctor to agree and say things should settle down.

Past Medical History

No significant previous medical history. Infrequent attender; prides self on being fit.

Medication

None. No allergies noted.

Family History

Mum — alive and well, 76
Dad — died in car accident when patient was 5

Social History

Smoking increased this year from ~10 to 15/day
Red wine after work; sometimes another glass before bed; 3–4 bottles/week recently
No time for hobbies; misses squash
Lives with partner; grown-up son (21)
Runs own small business making display shelving for shops; left school without qualifications; carpenter then own business 15 years; successful; moved to detached house 5 years ago

Demeanour

Somewhat anxious. Tries to make light of symptoms.

Physical Examination

Looks well; talking in full sentences; chatty
Pulse & BP normal; CVS exam normal

Negotiation / Management Script

Reassurance “not serious”: Obviously relieved, gets ready to go — “so I’m ok to start playing squash again?” Sits again if told no — “why not, if you say it’s not serious?”
Told “angina”: Denies possibility; reiterates fitness; “disease of old men.” Expect full plain-language explanation. Stop jargon and ask for simpler language if used.
Lifestyle advice: Initially unwilling to reduce work hours (“impossible”). If explained competently with reasons: will try to cut cigarettes; agree help with lifting; can take it easier during industrial fortnight shutdown. Still thinks squash would get them fit — warn against vigorous exercise until diagnosis clarified. Complies if reasoned and non-authoritarian; digs heels in if authoritarian.
999 advice: Should be advised to call 999 for prolonged pain or pain not associated with exertion.
Prescription (GTN and/or aspirin): Reluctant but eventually agrees if good explanation.
Urgent same-day hospital: Strongly resists (“haven’t the time”); refuses if insisted.
Chest pain clinic / cardiology referral: Initially resists; accepts if concern and process explained.
Bloods + ECG today: Resistant but accepts if can be done today.
Follow-up: Agrees to return for results and medication effect.
Alcohol: Will agree to reduce if reasoned argument given.

Information for the Student

Name: Michael / Mary Taylor · Age 55
PMH: No significant previous history
Medication: None
Recent: 3 years ago: tetanus immunisation

Primary Care Block · University of Buckingham