Florence Blackman 66 Year-old Female – Chest Pain 2
DIFFERENT VERSIONS OF THE ANSWER EXPERT FEEDBACK
(SOLUTIONS)
CONTENTS : ALL QUESTIONS, OLD-CARTS for the HPI,(PMH,FH,SH as
Needed),PHSICAL EXAM,EXAMS FEEDBACK,CASE
FINDINGS,FEEDBACK,DIFFERENTIAL RANKING ,DIAGNOSIS,CASE PLAN
1
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VERSION 1
Florence Blackman (66 y/o female) – Chest Pain
- CC: Intermittentsqueezing chest pain
- MSAP: Exertional “squeezing” mid-chest pain radiating to left arm, relieved by rest,
worse with cold - Associated dyspnea on exertion
- History: HLD, HTN, previous smoker, family hx of heart disease
- Stressful work
History Questions: - How can I help you today?
- Any othersymptoms we should discuss?
- Do you have any allergies?
- Are you taking any OTC or herbal medications?
- Any new or recent changes in medications?
- What doesthe pain / discomfort in your chest feel like? (squeezing, pressure, crushing,
burning, stabbing, aching, tingling, suffocating) - How severe (scale 1-10) is the pain in your chest?
- Does anything make the pain in your chest better or worse?
- What are the events surrounding the start of your chest pain?
- Is there a pattern to your chest pain?
- Have you had any trauma to your chest?
- Doesthe pain in your chest radiate someplace else? Where?
- Do you have unusual heartbeats(palpitations)?
- Doesthe pain get worse with breathing?
- Does your pain awaken you from yoursleep?
- Is your pain affected by what, when, or how much you eat?
- Do you presently have heartburn, a food or acid taste in your mouth?
- Do you drink alcohol? If so, what do you drink and how many drinks per day?
- Do you have any of the following problems: fatigue, difficulty sleeping, unintentional
weight loss or gain, fevers, night sweats? - Do you experience: SOB, wheezing, difficulty catching breath, chronic cough,sputum
production? - Does anything make yourshortness of breath better or worse?
- How long does your SOB last?
- Do you have any of the following: heat or cold intolerance, increased thirst, increased
sweating, frequent urination, change in appetite? - Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness,
numbness, tingling, tremor?
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- Do you have problems with: N/V, constipation, diarrhea, coffee groundsin your vomit,
dark tarry stool, bright red blood in your BM, early satiety, bloating? - How is your overall health?
- Tell me about your work.
- Tell me about daily exercise or sportsthat you play.
Physical Exam: - Vitals: pulse, BP, respirations
- Examine skin
- Neck: measure JVP (jugular venous pressure)
- Neck: auscultate carotid arteries
- Chest wall & lungs:
o Visual inspection of anterior & posterior chest
o Palpate anterior &posterior chest
o Auscultate lungs - Heart:
o Palpate for PMI (Point of Maximal Impact)
o Auscultate heart - Abdomen:
o Auscultate abdominal/femoral arteries
o Palpate abdomen - Extremities: Visual inspection of extremities
Assessment note: - F.B. is a 66 y/o Caucasian female presenting with 2-week h/o new onset, intermittent,
stable chest pain which radiates to the L arm, occurs with SOB, is worse with cold
temperatures and exertion, and improved by rest. On physical exam she is pain free with
stable vital signs. PMH risk factors include: distant history of smoking (5 pack/years), a
history of HTN, and high cholesterol, and a family history of coronary vascular disease. - Stresstest: 2-mm ST segment depression in inferior leads, 2, 3, and aVF and V3-6
Diagnosis: Coronary artery disease: stable angina
Plan: - Determine need for coronary angiography based on stress test results and ECHO. Her
Duke score of 10.5 is slightly above moderate risk, and arguments could be made for
both a trial at medication intervention since the pt needsimprovement on both HTN and
HLD
o Augment management of preexisting HTN and HLD with a BB (metoprolol 25 mg
XR daily); a statin (atorvastatin 40 mg daily); and ASA 81 mg daily - Continue use of HCTZ 25 mg daily
- Encourage lifestyle modification:
o Decrease intensity of aerobic workoutsfor next 3 months
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