Teaching case conference
Chest pain, one night in the ED
A fictional teaching case: what we saw, what we ruled out, and what we would do again.
Department of Emergency MedicineFictional, no patient dataOctober 2026
Presentation
58-year-old man, pressure in the chest
History
Two hours of central chest pressure at rest, radiating to the left arm. Hypertension, ex-smoker.
Examination
Anxious, sweating. Chest clear. No murmur.
BP162/94
HR96
SpO297%
Temp36.9C
- Arrives by ambulance
- 12-lead ECG read by a senior
- Blood tests sent, including troponin
- Repeat troponin drawn
Differential
Four causes we could not ignore
Fits
- Acute coronary syndrome: pressure, radiation, risk factors
- Aortic dissection: hypertension, severe pain
Less likely
- Pulmonary embolism: no leg signs, normal oxygenation
- Pericarditis: no positional change
Troponin rose over six hours
A rising pattern, well above the 99th percentile of 14 ng/L.
| Time | hs-troponin |
|---|---|
| 0 h | 18 |
| 3 h | 46 |
| 6 h | 92 |
Course
After the diagnosis
Diagnosis
Acute myocardial infarction.
Cardiology
Reviewed; plan agreed with the patient.
Procedure
Coronary angiography.
Home
Rehab and follow-up booked.
Take-home points
- ECG early, repeat it if pain changes.
- Trend the troponin; one value is a snapshot.
- Hold the dissection thought until you have excluded it.
Discussion
Questions
Presenter Dr. Sample Name, residentteaching@example.com