Context Matters: The Time I Sent Home the Patient With the Elevated Troponins

Note: I’ve changed some of the details of this story so that it does not match the real patients I based this story on.

I saw a patient in the ER for complaints of generally not feeling well. She was in her 60’s with diagnoses of heart disease and HTN. That was all I was able to tell. She did not speak English, and with the assistance of family members and a translator, I found that she had poor memory as well. 

Her exam showed that she was mildly hypertensive, comfortable, and with normal heart, lung and abdominal exams. 

Her EKG showed signs of LVH, but was otherwise unremarkable. 

Her troponin was 2. Other labs and CXR were normal. 

Here was a slam dunk admission.

I ordered that hospital’s protocol treatment for NSTEMI and called the cardiologist. The cardiologist agreed to admission.

I went back to explain the findings and plan for admission the patient and her family. I mentioned heart damage, and they told me that she had that recently at another hospital for some kind of heart problem. I contacted that hospital to get more information. The other hospital admitted her for an NSTEMI, troponin peaked at 8, and trended down to 3 by time of discharge. Discharge wss 2 days ago. I updated the cardiologist who recommended repeat troponin and EKG in 3 hours. She would be clear from a cardiac perspective if there were no changes.

I sent her home later that shift with unchanged troponins.

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One lesson that I try to emphasize in my junior trainees is that context means a lot in clinical medicine. One data point is rarely enough to make a decision. We need to know more of the story, but unfortunately most of the time we only get a snapshot. 

When you get an abnormal result, put it in the bigger context. It will usually make more sense and the way forward will be clear. 

When possible, try to get the bigger context. That can come in the form of old records (like it did in my situation), further history, further testing, or further clinical exam. Collect more data in an intelligent way, try to put it together, take a step back and try to make sense of it. There is most likely a pattern there that will guide you to the answer.

If you are interested in this or other topics in medical decision making, check out my book: A Guide to Clinical Decision Making.