MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-38 · Face-to-face · examination of a simulated patient
Breathless on exertion — examine the heart
A 74-year-old retired groundsman has come because he gets out of breath on the hill to the bowls club. His wife has made him book. You have eight minutes, a couch and a stethoscope.
Reviewed and kept current
Station family: Focused cardiovascular examination · 8-minute station · 1 min 30 s reading · Last editorial review: 16 October 2026 · Next scheduled refresh: 11 April 2027.
Candidate instructions
Read this as you would outside the room
You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.
| Information | |
|---|---|
| Your role | Foundation Year 2 doctor in a general practice. Your supervising GP is available. |
| Patient | Mr Leonard Pryce, 74, retired groundsman |
| Reason for appointment | Booked by his wife: “Short of breath walking up hills for a few months. Getting worse. Won’t come in on his own.” |
| Records | Hypertension for ten years: amlodipine 5 mg daily. Ex-smoker — stopped 25 years ago, 15 pack-years. No other past history. No known allergies. Last blood pressure 138/86 a year ago. No recent bloods. |
| Equipment | Examination couch that tilts, stethoscope, blood-pressure machine, pulse oximeter. A 12-lead ECG can be done by the healthcare assistant if you ask. |
Your task
•
Examine Mr Pryce’s cardiovascular system — and anything else you need to examine to find the cause of his breathlessness.
•
Ask only the questions you need as you go; a full history is not required.
•
Tell him what you have found, your working diagnosis and why, and agree a plan.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
Persona and manner
- Leonard Pryce, 74, retired groundsman; married to Hilary for 48 years; three grandchildren; a bowls club half a mile up the hill, which is your pride and joy.
- Courteous, understated, inclined to make light of things — “Hilary fusses.” You are not breathless sitting in the chair.
Opening line — say this verbatim
- “Hilary’s sent me. I get a bit puffed on the hill to the bowls club — it’s my age, surely? I don’t want a fuss.”
How to show the signs
- You cannot show anything: your heart sounds, pulse and chest are read out as findings when the doctor examines each part. Sit, lie back and sit forward as asked; breathe in and out and hold your breath when told.
- If asked to stand up or strain (“bear down”) while the doctor listens: do it — the finding is read out.
- If asked to walk up and down the room or do a step: you can do it, but after a minute you say you are getting puffed and would rather sit.
Volunteer freely if given the space
- For four or five months you have been getting out of breath on the hill — you used to walk straight up; now you stop twice. The last month it has started on the flat too — about two hundred yards and you need a breather.
- No cough, no wheeze, no phlegm. You are fine sitting down and fine in bed.
Only if asked
- Chest pain — only if asked about chest pain, tightness or pressure: “Once or twice, going up the hill, a tightness across here” (hand flat on the chest) “— it goes when I stop. I put it down to indigestion.” Never at rest. The last time was a week ago. It does not go to the arm or the jaw.
- Dizziness or faintness — only if asked directly whether you have felt faint, light-headed or nearly passed out, or have blacked out: “I went a bit swimmy at the top of the hill a fortnight ago — had to sit on the wall. It passed in a minute.” You did not black out. It has happened once. Otherwise keep this for the ‘anything to add’ line.
- No palpitations; no waking at night breathless; you sleep on two pillows, as you always have; no swollen ankles that you have noticed.
- No fever, no weight loss, no night sweats. No cough; no blood. No dental work recently. No rheumatic fever as a child that you know of.
- Family: your father died of “his heart” at 58; nobody with a heart murmur that you know of.
- Smoking: stopped 25 years ago, twenty a day before that. Alcohol: two pints on a Friday. You walk to the bowls club most days and play three ends when you get there.
- Medicines: the blood-pressure tablet every morning; nothing else, no aspirin. No allergies.
- Driving: you drive — a small car — to the supermarket, to your daughter’s twenty miles away, and to the bowls club when it is wet. Ordinary licence; you renewed it at 70.
Impact on daily life — home and work (only if asked)
- You have stopped carrying your bowls bag up the hill and have given up your place in the Saturday league; it has hit you harder than you let on.
- Hilary will not let you carry the shopping any more, which you find humiliating.
- You drive your grandchildren to swimming on Saturdays — you would hate to lose that.
Ideas, concerns and expectations
- Idea: age, and being “out of condition” since the winter.
- Concerns: that Hilary is right and it is your heart — your father died of his at 58; you have not said this to her.
- Expectation: to be told to lose a bit of weight and walk more; perhaps a blood test “for anaemia”.
Cues to deliver, timed
- Minute 1–2: “It’s just age, isn’t it? Everyone gets puffed on that hill.”
- While the doctor is listening to your heart, if the stethoscope has been on the chest for 10 seconds without a word: “Can you hear something? You’ve gone quiet.”
- If nothing has been said about driving by minute 7: “I’m still all right to drive, aren’t I? I take the grandchildren swimming.”
If the doctor summarises and asks whether you want to add anything
- If the swimmy turn has not come out: “There was one thing — a fortnight ago I went a bit swimmy at the top of the hill and had to sit on the wall. Hilary doesn’t know.”
- If it has: “Is it what my father had? He went at 58.”
How to respond to the doctor
- If the doctor explains that one of the heart valves has probably become narrowed and stiff with age, that this explains the breathlessness, the tightness and the swimmy turn, that it can be fixed, and that you need a heart scan and a specialist quickly — within two weeks: taken aback, then — “Fixed? At my age?” If answered honestly (yes, often, and it is the symptoms that decide): “Then let’s get on with it.”
- If the doctor says “it’s probably a touch of heart failure” or “your age” and arranges blood tests or a routine referral: you accept and thank them.
- If the doctor asks you to stop driving until the specialist has seen you, and explains why — the swimmy turn on exertion, and what could happen at the wheel: upset — “Who’ll take the grandchildren?” — then you agree if the doctor acknowledges it and says Hilary can drive meanwhile. If the doctor is vague (“be careful driving”), you carry on driving.
- If the doctor says plainly that the chest tightness on the hill is a warning and that you must not push through it: “Understood.”
- If told to keep walking on the flat but stop at the first sign of tightness or dizziness and not to carry heavy loads up the hill for now: “I can live with that.”
- If offered a tablet that “opens up the arteries” or a spray under the tongue without a scan first: you accept.
- If both carotids are pressed at the same time — “Steady.”
Do not
- Volunteer the chest tightness, the swimmy turn or your father’s death unless asked, or invited to add anything (apart from the timed cues).
- Use the words “valve”, “aortic” or “murmur”.
- Look breathless sitting in the chair.
Findings to give the candidate — only if asked for
This is an examination station. The role player cannot produce a murmur, a slow-rising pulse or a heaving apex: read out each finding as the candidate reaches that step — the pulse when it is felt at the wrist and the carotid, the apex when it is located, each auscultation area as the stethoscope is placed there, the lung bases when they are listened to. Do not offer findings for steps the candidate has not performed. (Where a separate examiner is present, the examiner reads them.)
General: comfortable at rest, not breathless sitting; no pallor, no cyanosis, no clubbing, no splinter haemorrhages; warm hands. Pulse: 68 per minute, regular, slow-rising at the carotid — a small, late-peaking pulse; no radio-radial or radio-femoral delay. Blood pressure: 118/94. Face and neck: no malar flush, no anaemia; JVP not raised. Praecordium: no scars; apex beat in the fifth intercostal space in the mid-clavicular line, forceful and sustained (heaving); no parasternal heave; a systolic thrill is felt at the upper right sternal edge if the candidate feels for it. Auscultation: first heart sound normal; second heart sound quiet, with the aortic component soft; a harsh, crescendo–decrescendo ejection systolic murmur, grade 4 out of 6, loudest at the upper right sternal edge, radiating to both carotids, louder when he sits forward and breathes out; no diastolic murmur; no murmur at the apex or axilla; no added sounds; the murmur becomes slightly softer, not louder, on standing or straining. Chest: clear, no crackles, no wheeze. Abdomen and legs: liver not enlarged; no sacral or ankle oedema; peripheral pulses present; calves soft. Observations, if asked for: SpO₂ 96% on air, respiratory rate 16, temperature 36.6 °C, weight 82 kg, height 1.75 m. ECG, if requested: sinus rhythm 68, normal axis, tall QRS complexes (S in V1 + R in V5 = 41 mm) with ST depression and T-wave inversion in I, aVL and V5–V6; no Q waves; PR interval and QRS duration normal.
2 · Examiner mark sheet — generic scheme plus the key facts for this case
Domain marks — with the key facts that earn a 4 at this station
| Domain (GMC wording) · key facts for this case | 1 | 2 | 3 | 4 | Score |
|---|---|---|---|---|---|
1 · Data gathering, technical and assessment skills
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.
3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here
The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.
| Mark | Domain 1 · Data gathering, technical and assessment skills | Domain 2 · Clinical management skills | Domain 3 · Interpersonal skills |
|---|---|---|---|
| 4 |
|
|
|
| 3 | Systematic cardiovascular examination with the pulse character, apex, second sound and the murmur with its radiation correctly elicited and named, plus the exertional symptoms and driving asked about; one of the blood pressure and pulse pressure, the JVP, the lung bases or the impact on his life missing. | Correct working diagnosis with the reasoning and the differentials, urgent referral for echocardiography and driving advice given; one of the ECG and bloods, the ‘no nitrate before the echo’, the activity advice or a specific follow-up missing. | Warm and clear; the age cue answered; driving advice given a little bluntly or one cue missed. |
| 2 | Listens in four areas but does not feel the carotid or locate the apex; murmur described but not characterised or timed; second sound not noticed; few questions — chest tightness or faintness never asked about; driving not mentioned. | Names a valve problem but requests a routine (non-urgent) echocardiogram or referral despite exertional presyncope and angina; driving advice vague (“be careful”, “see how you go”); differentials not reasoned; safety-net generic. | Examines competently but in silence; “can you hear something?” brushed off; the driving advice read out as a rule with no acknowledgement of the grandchildren; some jargon. |
| 1 | Disorganised, incomplete examination; stethoscope on the chest within the first minute with no pulse, blood pressure or JVP; no questions about red flags. Or unsafe: no meaningful examination; or presses both carotids at once; or examines in silence and reports nothing. | “A touch of heart failure” or “your age” — bloods and a review; no referral for echocardiography; no mention of driving; no safety-net. Or unsafe: hears of a near-faint on exertion and gives no driving advice; or starts a nitrate spray or another vasodilator before the echo; or tells him to push through the tightness to get fitter. | Dismissive (“you’re 74”) or alarming (“your valve could kill you”) with no explanation; he leaves frightened or unconvinced. Or unsafe: threatens to report him to the DVLA as the opening move (explaining that notification can become necessary is expected, not penalised); or mocks the ‘fuss’. |
4 · GMC feedback statements — where underperformance was identified — with case-specific examples
A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.
| GMC feedback statement | Underperformance it signals (generic) | Case-specific examples |
|---|---|---|
| 1 · Consultation | Disorganised or unstructured consultation | Starts with the stethoscope and works backwards to the pulse; findings gathered in no order and never pulled together before the diagnosis is offered. |
| 2 · Issues | Key issues or priorities not recognised | Does not see that the station has one question — is this murmur causing his symptoms? — and spends the time on weight, exercise and anaemia. |
| 3 · Time | Poor time management | Six minutes of examination; the diagnosis blurted at the bell; no referral decision, no driving advice, no safety-net. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Is told “slow-rising”, “second heart sound quiet” and “radiating to both carotids” and does not use them; is handed an ECG showing left ventricular hypertrophy with strain and calls it normal; does not connect the swimmy turn on the hill with the valve. |
| 5 · Examination | Physical examination or use of instruments not competent | Feels the radial pulse but never the carotid; does not locate the apex; listens with the diaphragm only, lying flat, and never sits him forward or listens to the neck; no blood pressure, no JVP, no lung bases; presses both carotids together. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | “A bit of heart failure” or “a murmur, probably nothing at your age” — no reasoning; cannot say why it is not a flow murmur or a cardiomyopathy; does not recognise that exertional chest tightness and a near-faint make the valve symptomatic. |
| 7 · Management | Management plan not reflecting current best practice | Routine cardiology referral or “we’ll do an echo and see”; starts a nitrate spray or a new blood-pressure tablet before the scan; no ECG; driving not mentioned, or “be careful”; nothing said about tightness at rest or a blackout; no plan to chase the referral. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | “Everyone your age gets a murmur” to a man who thinks his father’s heart is coming for him; no acknowledgement of the bowls club, the shopping or the grandchildren. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Ignores “can you hear something? You’ve gone quiet” and “I’m still all right to drive, aren’t I?”; never invites him to add anything, so the swimmy turn on the wall is never heard. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “You’ve got a grade four ESM at the aortic area with a soft A2 and LVH with strain — probably severe AS, so I’ll refer you urgently” — and he still thinks it is his age. |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- NICE NG208 (Heart valve disease presenting in adults, November 2021): offer an echocardiogram to adults with a murmur in whom valve disease is suspected and who have signs or symptoms (such as angina or breathlessness), an abnormal ECG, or an ejection systolic murmur with a reduced second heart sound (rec 1.1.2); offer urgent (within 2 weeks) specialist assessment that includes an echocardiogram — or, if not available, an urgent echocardiogram alone — to adults with a systolic murmur and exertional syncope; consider urgent (within 2 weeks) specialist assessment for a murmur with severe symptoms — angina or breathlessness on minimal exertion or at rest — thought to be due to valve disease (rec 1.1.3). Strictly, “offer” applies to exertional syncope and “consider” to severe symptoms; exertional presyncope with exertional angina and breathlessness at 200 yards is treated here as equivalent, supported by the DVLA presyncope rule, and an urgent echocardiogram alone is acceptable if the clinic is not available. An FY2 who refers urgently and says why is right; one who asks the supervising GP to confirm the route loses nothing.
- NICE NG208: refer to a specialist adults with moderate or severe valve disease of any type, and anyone with a bicuspid aortic valve (rec 1.1.7); offer an intervention to adults with symptomatic severe heart valve disease (rec 1.3.1); surgical valve replacement is first line at low or intermediate surgical risk, and transcatheter aortic valve implantation (TAVI) for non-bicuspid severe stenosis at high surgical risk or when surgery is unsuitable (recs 1.5.3–1.5.4). Asymptomatic severe disease is reviewed every 6 to 12 months with echocardiography (rec 1.4.1); mild aortic stenosis every 3 to 5 years (rec 1.4.2).
- Severity on echocardiography (2025 ESC/EACTS valvular heart disease guidelines, Eur Heart J 2025; British Society of Echocardiography practical guideline on aortic stenosis, 2021): high-gradient severe aortic stenosis = peak velocity 4 m/s or more, mean gradient 40 mmHg or more, valve area 1.0 cm² or less. Once severe aortic stenosis causes symptoms the outlook without treatment is poor, and the European guideline recommends valve intervention for symptomatic high-gradient severe stenosis — which is why symptoms, not the loudness of the murmur, set the urgency.
- The signs of significant aortic stenosis the candidate should elicit and name: a slow-rising, small-volume pulse felt at the carotid; a narrow pulse pressure; a forceful, sustained (heaving) apex that is not displaced until the ventricle fails; a thrill at the upper right sternal edge; a harsh, crescendo–decrescendo ejection systolic murmur loudest at the upper right sternal edge, radiating to the carotids, louder with the patient sitting forward in expiration; a soft or absent aortic second sound as the valve calcifies. Severity correlates with a late-peaking murmur, the soft second sound and the slow-rising pulse — not with loudness. Aortic sclerosis gives a similar but softer murmur with a normal pulse and second sound and no symptoms. Hypertrophic obstructive cardiomyopathy gives a jerky pulse and a murmur that gets louder on standing or during a Valsalva strain and does not radiate to the carotids; mitral regurgitation is pansystolic at the apex and radiates to the axilla.
- Symptoms are the trigger for intervention: exertional breathlessness, exertional angina (which can occur without coronary disease — the thickened ventricle outgrows its blood supply — though coronary disease often coexists and the specialist looks for it) and exertional presyncope or syncope (a fixed outflow cannot raise cardiac output when the peripheral vessels dilate). Ask about all three in every patient with an ejection systolic murmur, and ask whether they drive.
- DVLA (Assessing fitness to drive, cardiovascular disorders, last updated 7 November 2025) — aortic stenosis, Group 1 (car and motorcycle): without syncope, presyncope or symptoms likely to affect driving, may drive and need not notify; with syncope, presyncope or symptoms likely to affect driving, must not drive and must notify the DVLA — the licence is refused or revoked pending assessment and treatment. Group 2 (lorry and bus): severe stenosis must not drive and must notify even if asymptomatic. Mr Pryce holds an ordinary licence and has had presyncope on exertion: the sensible advice today is no driving until the specialist has assessed him, with the notification rule explained as information; the doctor records the advice (GMC, Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA).
- Medicines: in suspected severe aortic stenosis avoid starting nitrates and other vasodilators before the echocardiogram — a fixed outflow obstruction cannot compensate for a fall in systemic vascular resistance, so blood pressure and coronary perfusion can drop sharply; established antihypertensives are continued and adjusted by the specialist. There is no drug that slows the stenosis. NICE CG64 (rec 1.1.3): antibiotic prophylaxis against infective endocarditis is not recommended routinely for dental procedures; good dental hygiene and prompt treatment of infection are advised.
- Investigations an FY2 can start today: 12-lead ECG (left ventricular hypertrophy with a strain pattern supports significant stenosis; atrial fibrillation or conduction disease changes the picture); full blood count (anaemia worsens any valve lesion), renal function and electrolytes, lipids and HbA1c, and NT-proBNP, which NICE NG208 uses — at more than twice the upper limit of normal — as one marker favouring intervention in asymptomatic severe stenosis (rec 1.3.2). A chest X-ray is not needed to make the diagnosis. None of this delays the referral.
- NICE NG208 (recs 1.1.4–1.1.5) points elsewhere for two neighbouring presentations: a murmur with non-exertional syncope follows NICE CG109 (rec 1.1.4.2): transient loss of consciousness with a heart murmur — or during exertion — needs urgent cardiovascular assessment, reviewed by a specialist within 24 hours; Mr Pryce has had presyncope, not loss of consciousness, so NG208 applies; breathlessness without a murmur follows NICE NG106 (chronic heart failure), where the NT-proBNP level decides how urgently the echocardiogram is done.
Where candidates lose marks at this station
- Stethoscope first; the carotid pulse and the apex never felt.
- A murmur heard and reported as “a murmur” — not timed, not located, not radiated, the second sound never mentioned.
- Never asking about chest tightness, faintness or driving in a man with an ejection systolic murmur.
- “Probably a flow murmur at your age” — routine referral, or an echo and wait.
- A nitrate spray before the scan.
- “Be careful driving.”
Guidelines for this station
- NICE NG208 — Heart valve disease presenting in adults: investigation and management
- DVLA — Assessing fitness to drive: cardiovascular disorders (aortic stenosis)
- GMC — Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA
- ESC/EACTS 2025 Guidelines for the management of valvular heart disease (Eur Heart J 2025)
- British Society of Echocardiography — protocols and guidelines (aortic stenosis, 2021)
- NICE CG109 — Transient loss of consciousness (‘blackouts’) in over 16s
- NHS — Heart valve replacement (patient information)
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | Cardiovascular |
| Domain 3 · Clinical and professional capabilities | History, examination and differential diagnosis · Investigations: request, interpret, act · Managing risk · Communication with patients, relatives and carers · Using guidelines and evidence |
| Domain 5 · Patient presentations | Heart murmurs · Breathlessness · Chest pain · Blackouts and faints · Fitness to drive |
| Domain 6 · Conditions | Aortic valve disease · Ischaemic heart disease (including stable angina) |
| Station family | Clinical examination — Focused cardiovascular examination |
7 · My marks and reflection — practice log form
Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for P2-38
Revision link for this case: mdacumen.com/plab-2-osce/case-38-breathless-on-exertion
Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.
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