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An OSCE case involving a 46-year-old man presenting with recurrent chest pain and a known history of myocardial infarction. The registrar misinterprets the ECG as showing only an old LBBB, missing positive Sgarbossa criteria indicating a posterior STEMI equivalent. Candidates must recognise concordant ST depression in V2–V5, initiate ACS management including thrombolysis and DAPT, arrange urgent transfer to a PCI-capable centre, and provide structured bedside teaching and supervision.