Note from Dr. Pregerson: Thanks to Jerome Hoffman, MD, a giant in emergency medicine and a professor emeritus at the UCLA School of Medicine, for reviewing this topic with me.

Second Troponin v. Second History: I would like to be spread the following lesson to everyone in EM: “Before you do a second troponin, do a second history!” You need to really nail down the timing and duration of symptoms the best you can or you may be misled. Some patients speak their own language: “Constant” can mean “frequent.” Most of us already know that “no medical problems” can mean “no untreated medical problems” to a lot of people. It is safest to start with the assumption that all chest pain is unstable angina until proven otherwise, that the pain is episodic lasting five to 10 minutes, and that the troponin and ECG may both be useless.

HEART Score Logic: The HEART score is super useful and can help protect you if you send the wrong patient home, but you should still try to avoid doing that. The HEART score’s major blind spot is unstable angina because the troponin and ECG may be normal if pain lasts less than 20 to 30 minutes. Another caveat of the HEART score is grouping together all the patients with scores from 0-3. If the risk of this group is about one to two percent on average, logic dictates that patients with a score of 0-1 are actually at lower risk, but those with a score of 2-3 are likely at higher risk, perhaps three to four percent or even more. What is the actual risk associated with a HEART score of 3? We won’t know until someone does the study, but risk jumps to 10 to 20 percent once you hit the 4-6 score group. If you extrapolate the data, the risk of a MACE at 30 days is probably two to three times the HEART score, so for 3 it would be nine percent, if you use logic.

Head-Jolt sign: This is about 99% sensitive and 50% specific for meningitis. Have patients rapidly turn their head side to side. If it doesn’t hurt or they have to do it twice, make sure they don’t have meningitis. I will often grab their head and do it for them, but first definitely explain what I am doing to family members.

Eyes-Red eyes: Consensual photophobia or limbal flush suggests iritis or keratitis rather than conjunctivitis.

Pulmonary exam: Demonstrating how you want them to breathe and having them breathe more rapidly in and out is quicker and more sensitive for abnormal lung sounds. If you think you hear consolation when performing lung exam, ask a yes or no question. This can help continue your history, speed up your exam, and identify a pneumonia (a sort of modified egophony). After that and the end of an exhale, tell them to stop breathing and stick out their tongue (if no mask) while you listen to the heart with your stethoscope closer to the heart and without interference from lung sounds or, worse yet, speech. Bonus: Look at their tongue for hydration status.

Vascular-Pulses in the feet: Comparing pedal pulses is critical when there is a possibility of a knee dislocation, an aortic dissection, or acute limb ischemia, all of which can be sneaky and time-sensitive. Popliteal arterial injuries often are diagnosed late due to severe leg pain or spontaneous knee reduction. Aortic dissection rarely extends into an arm but almost always extends into a leg. Acute limb ischemia can mimic DVT, sciatica, or even a stroke.

Ortho-Pain location: Have them touch the exact spot that hurts the most. Without this and a confirmatory exam, you may end up imaging the wrong part of the spine or extremity. If you are lucky, it will only cause a delay; if you are not, it can cause a disaster. I have seen many misses or near misses due to this.

• Posterior circulation strokes mimicking a migraine but with something that doesn’t fit.
• Vertigo that doesn’t fit labyrinthitis or BPPV.
• Other posterior circulation strokes: a variety of acute presentations; 2.5 times more likely to be missed than anterior circulation strokes. Blurry vision=nystagmus.
• Anterior circulation strokes that mimic intoxication with altered mental status often from expressive or receptive aphasia.

PID is often missed because the exam can be unimpressive. Remember more than 50 percent of men and more than 80 percent of women have no symptoms with chlamydia, so if you use your logical brain, it follows many cases are mild. In terms of risk, remember that PID is not always an STI; it is caused by vaginal flora in about 15 percent of cases.

Fitz-Hugh-Curtis (FHC) is also often missed, and you are probably missing it if you are not diagnosing about one case a year. The classic case is pleuritic RUQ pain in a sexually active woman, normal LFTs, elevated D-dimer, and normal CT angiograph of the chest. If it is from chlamydia, patients almost never have pelvic symptoms. Incubation is usually about three weeks. Do a sexual history. If there is a new partner, consider FHC even if the pain is nonpleuritic. Gallstones can be a red herring.

HSV meningitis is often missed. Most of the cases I have diagnosed had been seen by at least one other clinician in the prior week. It often follows a mild primary infection that has just irritation but no rash or blistering. About 50 percent of HSV1-positive and about the same percentage of HSV2-positive patients have never had an outbreak, so it follows that mild cases likely occur and are missed. Meningitis can start mild, and elevated CSF RBCs only occur about half of the time.

Return Precautions: These are your safety net, and there’s a huge variance in what physicians write. The nucleus should always be to return if not improving or worse or if anything new happens. Logic: Most people don’t want to return for the same thing that you just sent them home for, so you must emphasize this, focusing on things like syncope, abdominal pain, fever, and vomiting.

Incidental Findings: Diagnose lung and adrenal nodules, ovarian cysts, etc., and give them copies, tell them to follow up, and write it in the aftercare. This can be a big medicolegal risk. It’s important that it is not so incidental when someone who doesn’t ovulate has free fluid in the abdomen.

Abnormal Labs and BP: From most common to least common include hypertension, glucose >LFTs, K+, Na+ >others.

Sedating Medications: Not just driving. Even taking a bus or walking home. Don’t rely on the pharmacist.  Malpractice usually doesn’t cover third parties. Read more: https://bit.ly/3K8tPs6.

Classic PE: Pleuritic chest pain, shortness of breath, tachycardia, and S1Q3T3 after starting an oral contraceptive on a long flight to get chemo.

Large PE Misses: About 20 percent of PEs are painless and probably about 50 percent of the large ones are painless, but this is rarely taught. The logic is that there is collateral circulation. Large PEs almost always cause SOB, however. These PEs often mimic ACS or sepsis due to tachycardia (rare in ACS) or low blood pressure, ischemic ECG changes, and elevated troponin/BNP/WBC. A bedside echo can really help if the patient is unstable, as can an ECG. Look for a dilated RV on the echo. Look for a new right axis or T-wave inversion in both inferior and anterior leads on the ECG because both of these are rare in ACS.

Small PE Misses: : Pleuritic chest pain only. The logic is that there is no collateral circulation so there is a lung infarct, which causes pain. No SOB, normal vitals, normal ECG, no known risk factors. Use PERC or D-dimer if you don’t have a more likely diagnosis. You may know the PERC, but do you also know the exclusion criteria? (https://bit.ly/3L7NRUz.)

Too Many Chest CTs: COVID is a more likely diagnosis most of the time for PERC so don’t dimer them unselectively! The logic is how many PEs have you and your colleagues diagnosed with a mildly elevated D-dimer or when you had a better explanation for symptoms but you were just CYA? Better than logic is logic and literature: Use age-adjusted D-dimer and YEARS criteria to minimize unnecessary CT. Both are validated and can be used in pregnant patients as well. (https://bit.ly/3L7NRUz.) Also know the causes of false-negative D-dimer (on thinners, symptoms less than a week).

Therapeutic Trials: Maalox relieves pain in 15 percent of cases of ACS. Why? The logical answer is coincidence, so before you order Maalox, ask if the pain is already improving. Do the same for NTG, and you will be less likely to get fooled by coincidences.

Second Troponin:Before doing a second troponin, do a second history to nail down the timing and duration as best as possible. Otherwise, you may end up wasting time, or worse, giving yourself false reassurance.

Pain Duration:Assume all cardiac chest pain is unstable angina until proven otherwise and that every chest pain patient has episodic pain lasting five-10 minutes, making the troponin and ECG useless.

HEART score:Not as useful if pain has resolved because the troponin and ECG may be useless. Score grouping may also overestimate risk in a patient with a score of 0-1 and underestimate risk in a patient with a score of 3. Use the info in scores, but don’t blindly follow them. Apply logic!