Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain

Diagnosis (Berl). 2023 Jul 14;10(3):316-321. doi: 10.1515/dx-2022-0017. eCollection 2023 Aug 1.

Abstract

Objectives: Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning.

Case presentation: A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction.

Conclusions: An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.

Keywords: Bayes theorem; diagnostic error; myocardial perfusion scan.

Publication types

  • Case Reports

MeSH terms

  • Bayes Theorem
  • Chest Pain / diagnosis
  • Chest Pain / etiology
  • Clinical Reasoning
  • Electrocardiography* / methods
  • Female
  • Humans
  • Middle Aged
  • ST Elevation Myocardial Infarction*