Note: Editing this month’s case was especially challenging due to legibility issues. The case was selected despite the legibility issue because it is an excellent example of a key liability risk. Plain-text versions of some documents have therefore been included below the original documents to help the reader understand the case.

A 58-year-old woman was on vacation with her husband, visiting her in-laws. She began to experience chest and jaw pain, and they stopped in a small town with a population of about 4000 people. They went to the town’s hospital and checked into the Emergency Department.

The nursing triage note is shown below. The handwriting is difficult to read, therefore a typed interpretation of the relevant information is shown below.

The doctor working in the ED that day was trained in Family Medicine. He saw her and filled out a T-sheet describing her presentation. The initial assessment is shown below. The workup, results, and disposition will be shown on subsequent pages.

What tests should be ordered for this patient?

Continue to the next page to see what the physician ordered and the results!

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