Quick answer
How should I present this chest-pain case on rounds?
Lead with the patient’s age, major cardiovascular risks, and two hours of ongoing pain at rest. Give the discriminating pain features, then only the relevant background. State the lateral ST depression and dynamic troponin rise before committing to a leading diagnosis of non-ST-elevation acute coronary syndrome, likely NSTEMI. End with immediate priorities, dangerous alternatives, and the important data that remain unknown.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation after the initial ECG and the two-hour troponin result are available.
A supervising resident or attending who needs a prioritized new-patient presentation.
History, medication and social history, initial ECG, and serial high-sensitivity troponin T. Vital signs, allergies, and examination findings are not supplied.
About 90 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Johnson is a 58-year-old man with hypertension, type 2 diabetes, and active tobacco use who presents with two hours of chest pain at rest.
The pain began at rest, is substernal, rates 7 out of 10, and radiates to his left arm. It has not improved with antacids. He initially wondered whether it was heartburn, but he is worried about a heart attack because his father died of an MI at age 62.
His history includes hypertension for five years and type 2 diabetes for three years. He takes metformin 1,000 milligrams twice daily and lisinopril 10 milligrams daily. He has a 20-pack-year smoking history and currently smokes; he drinks about two beers nightly.
The initial ECG shows sinus rhythm with 1 millimeter of horizontal ST depression in V4 through V6 and no ST elevation. High-sensitivity troponin T was 84 nanograms per liter on arrival, above the 0-to-14 reference range, and rose to 176 at two hours.
My leading diagnosis is non-ST-elevation acute coronary syndrome, most likely NSTEMI, based on ischemic pain at rest, lateral ST depression, and a dynamic troponin rise. Aortic dissection and pulmonary embolism remain dangerous alternatives to reassess if the history or examination suggests them.
I would keep him on a monitored acute chest-pain pathway, assess hemodynamic stability, allergies, bleeding risk, and contraindications, and obtain urgent emergency and cardiology input. Aspirin should be given when appropriate and not contraindicated; further antithrombotic and invasive management should follow the complete assessment and local protocol.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Identify the patient and make the risk audible immediately
“Mr. Johnson is a 58-year-old man with hypertension, type 2 diabetes, and active tobacco use who presents with two hours of chest pain at rest.”
Why it belongs: Age, vascular risk, acute time course, and pain at rest change urgency and frame every detail that follows.
This is a 58-year-old male, known case of hypertension and diabetes, complaining of chest pain.
Mr. Johnson is a 58-year-old man with hypertension and type 2 diabetes who presents with two hours of chest pain at rest.
Why: A person-first noun and an active presenting phrase sound more natural; the time course and rest onset carry more clinical signal than ‘known case of.’
History of present illness
Present the features that support or challenge myocardial ischemia
“The pain began at rest, is substernal, rates 7 out of 10, and radiates to his left arm. It has not improved with antacids. He initially wondered whether it was heartburn, but he is worried about a heart attack because his father died of an MI at age 62.”
Why it belongs: Location, radiation, rest onset, persistence despite antacids, and the patient’s concern are meaningful; unrelated review-of-systems detail would dilute this signal.
The pain is radiating in character and antacids did not relieve him.
The substernal pain radiates to his left arm and has not improved with antacids.
Why: Pain radiates; a person is relieved. The preferred version keeps the symptom as the grammatical subject and is easier to follow aloud.
Relevant background
Compress risk factors, medications, and social context
“His history includes hypertension for five years and type 2 diabetes for three years. He takes metformin 1,000 milligrams twice daily and lisinopril 10 milligrams daily. He has a 20-pack-year smoking history and currently smokes; he drinks about two beers nightly.”
Why it belongs: These comorbidities and tobacco exposure change pretest probability and management context. Retirement does not change the immediate assessment, so it can wait.
He is on his usual diabetes and blood-pressure medicines.
He takes metformin 1,000 milligrams twice daily and lisinopril 10 milligrams daily.
Why: Expanding dosing abbreviations is clearer for an international clinical audience and safer when spoken.
Objective data
State the decisive results and their trend
“The initial ECG shows sinus rhythm with 1 millimeter of horizontal ST depression in V4 through V6 and no ST elevation. High-sensitivity troponin T was 84 nanograms per liter on arrival, above the 0-to-14 reference range, and rose to 176 at two hours.”
Why it belongs: The lateral ST depression and rising troponin convert a concerning symptom story into a much more specific working diagnosis. The direction of change matters as much as the individual values.
Troponin was positive and the ECG had changes.
Troponin rose from 84 to 176 nanograms per liter over two hours, and the ECG shows horizontal ST depression in V4 through V6.
Why: Exact values, timing, and leads let the listener judge the evidence instead of accepting a vague interpretation.
Assessment
Commit to a leading diagnosis and show why
“My leading diagnosis is non-ST-elevation acute coronary syndrome, most likely NSTEMI, based on ischemic pain at rest, lateral ST depression, and a dynamic troponin rise. Aortic dissection and pulmonary embolism remain dangerous alternatives to reassess if the history or examination suggests them.”
Why it belongs: The assessment commits, names the evidence, and keeps only time-critical alternatives active. It does not present a long unranked differential.
This is ACS until proven otherwise; differentials include STEMI, NSTEMI, unstable angina, dissection, PE, and reflux.
My leading diagnosis is non-ST-elevation acute coronary syndrome, most likely NSTEMI, because of the ischemic pain, ST depression, and dynamic troponin rise.
Why: The preferred version ranks the diagnosis and connects it to evidence; the less-clear version mixes subtypes and alternatives without showing reasoning.
Plan
Name immediate priorities while preserving clinical boundaries
“I would keep him on a monitored acute chest-pain pathway, assess hemodynamic stability, allergies, bleeding risk, and contraindications, and obtain urgent emergency and cardiology input. Aspirin should be given when appropriate and not contraindicated; further antithrombotic and invasive management should follow the complete assessment and local protocol.”
Why it belongs: The plan is urgent and directional without inventing contraindications, doses, examination findings, or an institution-specific pathway.
I will start the ACS protocol and send him to the cath lab.
I would keep him on a monitored acute chest-pain pathway and obtain urgent cardiology and emergency input while checking contraindications and bleeding risk.
Why: The preferred wording states the immediate actions supported by the case and leaves invasive timing to findings, risk, and local protocol.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Vital signs and focused examination
Say: “Vital signs and examination findings are not provided in this simulation, so I would assess his hemodynamic and respiratory status immediately.”
Do not say that the patient is stable, comfortable, or euvolemic unless you have measured or examined it.
Allergies and contraindications
Say: “Allergies, bleeding history, and treatment contraindications still need to be verified.”
Medication decisions cannot be presented as unconditional when these safety facts are absent.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Two hours of pain at rest with left-arm radiation | Lead | Time course and ischemic features define the acute problem. |
| Hypertension, diabetes, smoking, and family history | Include | These details raise cardiovascular risk and strengthen the problem representation. |
| Initial belief that the pain was heartburn | Compress | The idea matters for patient perspective, but it should not distract from urgency. |
| Retired employment status | Omit | It does not change the immediate emergency assessment in this presentation. |
| Lateral ST depression and serial troponin rise | Lead | These are the decisive objective findings and should immediately precede the assessment. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
Why are you calling this NSTEMI rather than unstable angina?
The case has a significant rise in high-sensitivity troponin T from 84 to 176 nanograms per liter together with an ischemic symptom pattern and ST depression. That myocardial-injury evidence favors NSTEMI over unstable angina, while the complete clinical assessment must still exclude other causes of troponin elevation.
What information do you need before finalizing treatment?
I still need current vital signs, cardiopulmonary examination, oxygenation, allergies, bleeding history, renal function, treatment contraindications, and the broader emergency assessment. Those items are not present in the source case and should not be assumed.
Which dangerous alternatives are still important?
Aortic dissection and pulmonary embolism remain important if their characteristic history or examination findings emerge. The current pattern strongly supports acute coronary syndrome, but the source case does not provide a complete examination to close those branches.
Self-check
A 30-second check before you present
- Open with age, relevant risks, acute problem, and time course.
- Organize the HPI around discriminating positives and negatives.
- Keep background details only when they change risk or management.
- Give exact ECG leads, troponin values, and timing.
- State a ranked leading diagnosis and connect it to evidence.
- Name dangerous alternatives selectively, not as a memorized list.
- State missing vital signs, examination, allergies, and contraindications.
- End with immediate priorities and defer specifics to the full assessment and local protocol.
Common presentation problems
Repair the habits that make a case hard to follow
Starting with every past diagnosis before saying why the patient is here
Repair: Put the acute chest pain, its duration, and major cardiovascular risks in the first sentence.
Calling the ECG abnormal and troponin positive
Repair: Give the affected leads, ST pattern, exact serial values, and interval so the listener can evaluate the evidence.
Listing ACS subtypes as separate unranked differentials
Repair: Commit to NSTE-ACS, likely NSTEMI, then state the evidence and only the dangerous alternatives still under consideration.
Inventing stability because vital signs are absent
Repair: Say that hemodynamic and respiratory status must be assessed immediately.
Frequently asked questions
Oral case presentation questions
Should I say every medication in an emergency presentation?
Give medications that affect the assessment or immediate plan, then be ready with the complete list. Here, diabetes and blood-pressure therapy provide context, while allergy and contraindication status must still be verified.
Can I diagnose NSTEMI in the opening sentence?
Usually let the opening sentence frame the problem, then present the supporting data before your assessment. If your setting expects a diagnosis-first update, adapt the order to the listener and local convention.
How long should this presentation be?
This worked example targets about 90 seconds. Actual length varies by setting, acuity, learner level, and supervisor expectations; concise does not mean omitting information needed for immediate safety.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case cardio_001. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- 2025 Guideline for the Management of Patients With Acute Coronary SyndromesAmerican Heart Association · accessed 2026-08-27
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-08-27
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-08-27
Published: · Last source, safety, and language review: