Case Summary
Middle-aged male presented with atypical chest pain. Initial workup was incomplete: a single troponin was drawn without serial follow-up, and the patient was discharged before NSTEMI could be ruled out.
Timeline
- T+0h — Presentation, vital signs stable, atypical chest pain
- T+1h — Single troponin: negative
- T+3h — Repeat troponin not ordered ⚠
- T+8h — Discharge with outpatient follow-up ⚠
- T+38h — Return, troponin elevation, NSTEMI confirmed
Missed Signals
- Single negative troponin in atypical presentation does not exclude NSTEMI per ACC/AHA NSTEMI Guidelines (Amsterdam et al., 2014). Serial troponins at 3–6 hour intervals are standard.
- HEART Score not documented in initial assessment.
System Factors
- Discharge occurred during shift handoff window. Continuity may have been a contributing factor.
Teaching Case — Q&A Format
(continues below…)