Chest Pain in a Shop Owner
Case ID: chest-pain-acs
Preview JSON
{
"id": "chest-pain-acs",
"title": "Chest Pain in a Shop Owner",
"specialty": "Emergency Medicine",
"difficulty": "medium",
"estimatedMinutes": 12,
"xpReward": 100,
"tags": [
"chest pain",
"emergency",
"cardiology",
"india-opd"
],
"learningObjectives": [
"Identify red flags in acute chest pain",
"Order urgent ECG and cardiac markers",
"Start first-line management and urgent escalation"
],
"patient": {
"name": "Ramesh Verma",
"age": 54,
"sex": "Male",
"occupation": "Shop owner",
"languageStyle": "mixed",
"personality": "Concerned but cooperative",
"healthLiteracy": "medium",
"emotionalState": "Anxious",
"context": "Primary breadwinner, worried about missing work"
},
"openingLine": "Doctor, I have tightness in my chest since morning.",
"hiddenDiagnosis": {
"name": "Acute coronary syndrome",
"explanation": "Typical ischemic chest pain with autonomic symptoms and elevated troponin."
},
"diagnosisSynonyms": [
"heart attack",
"myocardial infarction",
"mi",
"acs"
],
"differentials": [
{
"name": "Gastroesophageal reflux disease",
"likelihood": "low"
},
{
"name": "Costochondritis",
"likelihood": "low"
},
{
"name": "Pulmonary embolism",
"likelihood": "medium"
}
],
"history": [
{
"id": "hx-chest-onset",
"category": "hpi",
"questionHints": [
"when did it start",
"since when",
"duration"
],
"patientAnswer": "It started around 45 minutes ago while opening my shop.",
"requiredForScore": true
},
{
"id": "hx-chest-character",
"category": "hpi",
"questionHints": [
"describe pain",
"tightness",
"pressure"
],
"patientAnswer": "It feels like heavy pressure in the center of my chest.",
"requiredForScore": true
},
{
"id": "hx-chest-radiation",
"category": "red_flags",
"questionHints": [
"go anywhere",
"radiate",
"arm",
"jaw"
],
"patientAnswer": "Yes, the pain is moving to my left arm and shoulder.",
"requiredForScore": true,
"redFlag": true
},
{
"id": "hx-chest-associated",
"category": "red_flags",
"questionHints": [
"associated symptoms",
"sweating",
"nausea",
"vomit"
],
"patientAnswer": "I am sweating a lot and felt nauseated twice.",
"requiredForScore": true,
"redFlag": true
},
{
"id": "hx-chest-past",
"category": "past_history",
"questionHints": [
"history",
"diabetes",
"bp",
"sugar"
],
"patientAnswer": "I have diabetes for 8 years and I smoke around 8 cigarettes a day.",
"requiredForScore": true
},
{
"id": "hx-chest-allergy",
"category": "allergies",
"questionHints": [
"allergy",
"aspirin allergy",
"medicine reaction"
],
"patientAnswer": "No known medicine allergies, including aspirin.",
"requiredForScore": true
}
],
"physicalExam": [
{
"id": "ex-vitals-chest",
"examType": "vitals",
"label": "Check vital signs",
"finding": "BP 150/95 mmHg, HR 104/min, RR 20/min, SpO2 96% on room air",
"abnormal": true,
"requiredForScore": true
},
{
"id": "ex-cvs-chest",
"examType": "cardiac",
"label": "Focused cardiovascular exam",
"finding": "Tachycardia present. No murmurs. Peripheral perfusion preserved.",
"abnormal": true,
"requiredForScore": true
}
],
"tests": [
{
"id": "test-ecg-chest",
"name": "ECG",
"category": "bedside",
"result": "ST depression in lateral leads",
"interpretation": "Suggestive of myocardial ischemia",
"cost": 500,
"timeMinutes": 5,
"requiredForScore": true
},
{
"id": "test-troponin-chest",
"name": "Troponin I",
"category": "lab",
"result": "Elevated",
"interpretation": "Supports acute myocardial injury",
"cost": 1800,
"timeMinutes": 20,
"requiredForScore": true
},
{
"id": "test-cxr-chest",
"name": "Chest X-ray",
"category": "imaging",
"result": "No acute cardiopulmonary abnormality",
"interpretation": "No alternate acute chest pathology seen",
"cost": 700,
"timeMinutes": 12,
"unnecessary": true
}
],
"treatments": [
{
"id": "tx-aspirin-chest",
"name": "Chewed Aspirin 325 mg",
"category": "medication",
"effect": "Early antiplatelet therapy initiated.",
"safe": true,
"requiredForScore": true
},
{
"id": "tx-antacid-only-chest",
"name": "Only Antacid and Observe",
"category": "supportive",
"effect": "Misses time-critical ACS management.",
"safe": false,
"dangerous": true,
"contraindicationWarning": "Unsafe as sole therapy in suspected ACS."
}
],
"escalationOptions": [
{
"id": "esc-cardiology-urgent-chest",
"label": "Urgent cardiology referral / monitored transfer",
"result": "Senior team informed and patient moved to monitored care.",
"requiredForScore": true
},
{
"id": "esc-call-senior-chest",
"label": "Call medicine senior for bedside review",
"result": "Senior resident arrives for co-management.",
"requiredForScore": true
}
],
"criticalActions": [
{
"id": "crit-chest-onset",
"type": "ask",
"label": "Ask onset and duration",
"points": 5,
"category": "history",
"match": [
"hx-chest-onset"
]
},
{
"id": "crit-chest-character",
"type": "ask",
"label": "Ask pain character",
"points": 5,
"category": "history",
"match": [
"hx-chest-character"
]
},
{
"id": "crit-chest-radiation",
"type": "ask",
"label": "Ask pain radiation",
"points": 5,
"category": "history",
"match": [
"hx-chest-radiation"
]
},
{
"id": "crit-chest-associated",
"type": "ask",
"label": "Ask associated symptoms",
"points": 5,
"category": "history",
"match": [
"hx-chest-associated"
]
},
{
"id": "crit-chest-vitals",
"type": "exam",
"label": "Check vital signs",
"points": 10,
"category": "exam",
"match": [
"ex-vitals-chest"
]
},
{
"id": "crit-chest-ecg",
"type": "test",
"label": "Order ECG",
"points": 5,
"category": "reasoning",
"match": [
"test-ecg-chest"
]
},
{
"id": "crit-chest-troponin",
"type": "test",
"label": "Order troponin",
"points": 5,
"category": "reasoning",
"match": [
"test-troponin-chest"
]
},
{
"id": "crit-chest-diagnosis",
"type": "diagnosis",
"label": "Identify ACS diagnosis",
"points": 5,
"category": "reasoning"
},
{
"id": "crit-chest-aspirin",
"type": "treatment",
"label": "Give aspirin if no contraindication",
"points": 5,
"category": "management",
"match": [
"tx-aspirin-chest"
]
},
{
"id": "crit-chest-escalate",
"type": "escalation",
"label": "Urgent escalation",
"points": 5,
"category": "management",
"match": [
"esc-cardiology-urgent-chest",
"esc-call-senior-chest"
]
},
{
"id": "crit-chest-safe",
"type": "escalation",
"label": "Avoid unsafe discharge",
"points": 20,
"category": "safety",
"match": [
"esc-cardiology-urgent-chest",
"esc-call-senior-chest"
]
},
{
"id": "crit-chest-communication",
"type": "communication",
"label": "Use empathy and explain urgency",
"points": 10,
"category": "communication"
},
{
"id": "crit-chest-efficiency",
"type": "test",
"label": "Use focused tests first",
"points": 10,
"category": "efficiency",
"match": [
"test-ecg-chest",
"test-troponin-chest"
]
},
{
"id": "crit-chest-doc",
"type": "documentation",
"label": "Document assessment and plan",
"points": 5,
"category": "documentation",
"match": [
"chest pain",
"ecg",
"plan"
]
}
],
"dangerousActions": [
{
"id": "danger-chest-antacid-only",
"type": "treatment",
"label": "Treat as acidity only",
"points": -10,
"category": "safety",
"match": [
"tx-antacid-only-chest"
]
}
],
"scoringRubric": {
"history": 20,
"exam": 10,
"reasoning": 15,
"safety": 20,
"communication": 10,
"efficiency": 10,
"documentation": 5,
"management": 10
},
"teachingNotes": {
"summary": "This was an ACS-pattern chest pain requiring rapid structured assessment.",
"correctReasoning": "Typical pressure-like pain with radiation, autonomic symptoms, and positive biomarkers indicates ACS until proven otherwise.",
"commonMistakes": [
"Dismissing chest pain as gastritis without ECG",
"Skipping risk-factor and allergy checks before treatment",
"Delayed escalation despite high-risk presentation"
],
"nextSteps": [
"Repeat with strict 5-minute chest pain checklist: onset, character, radiation, associated symptoms, risk factors."
]
}
}