, Volume 28, Issue 4, pp 583-590
Date: 06 Oct 2012

NSTEMI or Not: A 59-Year-Old Man with Chest Pain and Troponin Elevation

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A 59-year-old African-American man with a history of hypertension, hyperlipidemia, and cerebrovascular disease presented to the emergency department complaining of chest pain. He stated that the pain began suddenly while he was seated at home several hours prior to presentation. He described the pain as throbbing, 9 out of 10 in intensity, substernal, and associated with nausea, diaphoresis, and dyspnea. He stated that the pain radiated to his left leg but not to his arm or jaw. The pain resolved spontaneously after an hour, but then recurred 3 hours later. He had never experienced pain like this before. He initially delayed coming to the hospital, expecting the chest pain to subside spontaneously again; but finally his family brought him in when he became disoriented and confused.


One of my rules of thumb when constructing a differential diagnosis is to factor in the abruptness of symptom onset as well as pace. Symptoms that present themselves at “the snap ...

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.