Sharp central chest pain for two days, worse lying flat

Stage 1 of 2

Ingrid Haugen walked into the department after two nights of poor sleep. The pain is sharp rather than heavy, sits behind the sternum and catches when she lies back on the trolley. Sitting forward eases it. She points to her left shoulder blade when asked where else she feels it. There is a scratchy sound at the left sternal edge that comes and goes with the heartbeat. The chest is clear, the calves are soft and she is not breathless at rest.

Stage 2 of 2

She is kept overnight. The troponin taken on arrival and again at three hours are both below the assay limit, and the echocardiogram shows no pericardial fluid and normal ventricular function. She has slept sitting up. This twelve-lead is recorded before the morning ward round.