This page reveals the answer
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Five progressive clues
These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 58-year-old man is brought to the emergency department after 40 minutes of chest pressure that started while he hauled a heavy suitcase up a stairwell, terrified he would miss his connecting flight. He is pale, sweaty, and keeps a fist pressed to the center of his chest.
Clue 2
He describes a heavy, squeezing pressure behind the breastbone that spreads to his left arm and up into his jaw, with nausea and a cold sweat. It is not sharp, does not change with breathing or position, and eased somewhat when he sat down but keeps returning in waves. He has hypertension, high cholesterol, and a 30-pack-year smoking history.
Clue 3
He looks anxious and diaphoretic. Blood pressure is identical in both arms, the lungs are clear, and there is no rub heard over the chest; on careful listening there is a faint extra heart sound just before the first heart sound. The chest wall is not tender to firm palpation.
Clue 4
A 12-lead ECG shows flat, horizontal ST-segment depression of about 1.5 mm with inverted T waves across the lateral leads (V4 through V6), without any diffuse dome-shaped ST elevation or PR-segment depression. A portable chest X-ray shows a normal-width mediastinum and clear lung fields.
Diagnosis
Acute Coronary Syndrome
Why the diagnosis fits
Exertional substernal pressure radiating to the left arm and jaw with diaphoresis and nausea in a smoker with hypertension and hyperlipidemia is the classic ischemic presentation, and clue 5 seals it: a dynamic high-sensitivity troponin rise from 48 to 310 ng/L paired with horizontal ST-depression and T-wave inversion in the lateral leads defines acute myocardial ischemia/injury. The single KEY DISCRIMINATOR is the dynamic troponin rise-and-fall with ischemic (ST-depression/TWI) ECG changes: acute pericarditis gives diffuse concave ST-elevation with PR-depression, pleuritic/positional pain and a friction rub with a flat or minimally elevated troponin; pulmonary embolism is pleuritic and hypoxemic with RV strain; aortic dissection produces tearing pain, a blood-pressure differential between arms, and a widened mediastinum. Equal arm pressures, absent rub, clear lungs, and non-pleuritic exertional pain exclude those mimics.
Educational reference
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Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.