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This case study presents a detailed analysis of a 49-year-old female patient experiencing intermittent squeezing chest pain. A comprehensive history, physical exam findings, and a detailed analysis of the patient's condition. It provides insights into the diagnostic process, differential diagnoses, and management strategies for chest pain. The case study also includes exercises and questions to test understanding and critical thinking skills.
Typology: Exams
1 / 31
The following table summarizes your performance on each
section of the case, whether you completed that section or not.
Time spent: 1dy 13hr 58min
29secStatus: Submitted
Case Section Status
Your
Score
Time spent
Performance Details
History Done 63% 12hr
5m
in 12sec
questions asked,22 to
the case's list
correct, 13 missed
relative
Physical exams Done 83%
13hr
53 exams
performed, 0
partially correct,
case's list
correc to the
t, missed
relative
52mi
n
55se
c
Key
findin
gs organization
Done
34min
40sec
14 findings listed; 16 listed by the case
Problem
Done 1hr
9m
in 29sec
150 words long; the case's was 117 words
stateme
nt
Differentials Done 88%
13min
14sec
items in
the to
misse relativ
d e
DDx, 7
correct, 1
the case's list
History Notecard by AA on case
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
patient's reason(s) for the encounter and add additional symptoms obtained
fromfurther questioning.
column "OLDCARTS". Capture
theand row.
symptoms.(Remember to consider the patient's age and ris factors.) Use
k you
r
ideas to help guide your examinati the case. in the next section of
physical on
HPI Sx = chest pain
Sx
Sx
Sx
Sx
Sx
Onset
2.5 hours ago
Location deep in chest, pierces
Differenti
als
ranking
Done 88%
(lead/a
lt
score)
(must
not
miss
score)
7mi
n
38se
c
Tests Done 89%
50min
23sec
tests
relativ
e
ordere
d, to
the
correct,
1case's
list
missed
Diagnosis Done 100% 21sec
Manageme
nt plan
Done
46min 0sec
1645 words long; the case's was 79 words
Exercises Done
32mi
n
51se
c
3 of 5
correct
partially correct
(of scored items only)
(of
scored
items
only)
through back
History of Present Illness
Category
Data entered by AA
Reason for Encounter Chest pain
Histor of presen illness
y t
A 57 - year-old female 10 days status post inferolateral
STEMI with stent placement, presents to the ED
with a 2.5-hour history of progressively worsening
chest pain. The pain is sharp and stabbing, gets
to pierce through her back with inspiration. Pain
is relieved by sitting up and leaning
partiall forward.
y
She mild nausea vomiting, denies
report without fever/chills,
s
palpitations, lightheadedness/syncop SOB, cough, URI, or
e,
extremity/catheterization site or swelling. She reports
pain
compliance with her antiplatelet medications (ASA
Duration
Characteristics
worsens with deep inspiration
Aggravating
worsens when laying
down, moving, and
breathing
Relieving eased pain when leaning
forward
Timing /
Treatments
Severity 8/
and clopidogrel), pantoprazole, and aspirin since
discharge. On exam, patient is febrile, shallow
respirations at norma rate, low-normal oxygen
l
saturation, and has pericardial friction rub. PMH
is significant for hypertension, tobacco
hyperlipidemi
a,
abuse, obesity, and family history of heart attack and
type- 2 diabetes.
Past Medical History
Medications
Allergies
Preventive Health
Family History
Category
Data entered by AA
Family History Fathe - Heart attack, 59 years old
r
Category
Data entered by AA
Past Medical History Hypertension Hyperlipidemia
Hospitalizations / Surgeries Acute
Balloo
n
inferolateral
PCI/stenting
angioplasty
wall
of
of
ST-elevation
the righ
t
the left
myocardial
coronary
artery
circumflex
infarction with
artery.
Category
Data entered by A
Medications Clopidogrel
Atorvastatin
Pantoprazole
Aspirin 81
mg
mg
mg
mg
at bedtime
Category
Data entered by AA
Allergies Bactrim (rash)
Category
Data entered by AA
Preventive health Up to date immunizatio
n
annually. Reports
gynecologynormal.
including flu
exam was
shots
Mothe
r
Sister - Type 2 Diabetes
Social History
Category
Data enter d by AA
Social History Freelance worker, telephone sales. Smoked a pack and a
half for the past 25
years
Quitte
d
since she’d
the heart
attac
k
and takes a
health
y
heart diet.
Review of Systems
Category
Data entered by AA
General
Slightl
y
fatigued. Laying still to avoid movement,
breathing slowly.
Integumentar
y
/ Breast Warm skin; no significant diaphoresis.
HEENT / Neck Denies any problems with headaches, double vision, difficulty with
night vision,
hearing
problems, ear pain, sinus
problems,
chron
ic
sore
throat
s,
or difficulty swallowing.
Cardiovascular Chest pain. Heart attack 10 days ago.
Denies history of irregular heartbeats
nor Hypertension
Hyperlipidemia
palpitations.
Respiratory Denies wheezing and
sputu
m
production.
Gastrointestinal
Report
s
mild nausea and reflux.
Genitourinary Denies urinary frequency, pain, incontinence, or difficulty.
Musculoskeletal Denies chest injury. No problems with
muscle
s
and joints.
Allergic / Immunologic
Endocrine Denies problems with heat or cold intolerance, increased thirst,
increased sweating, frequent urination,
or
change in appetite.
Hematologic /
Lympha
tic
No
reports of bruising, bleeding
gums, sites of increased
bleeding.
nose bleeds, or other
Neurologic Denies dizziness, seizures, numbness, or weakness.
Psychiatric
Report
s
nervousness due to chest pain.
Physical Exams
Data entered by AA
Category
General Obese with a BMI of 29.4.
AOx
Skin
is dry and febril
e.
Skin Skin warm and dry with no lesions.
Nails withou
t
ridgin
g,
pitting
or peeling.
Capillary refill < 2 sec.
Quincke’s
Test:
Blanching observed.
HEENT / Neck Head: Normocephalic, atraumatic, no deformities, facial
features symmetric.Temporal arteries non-tender
to palpation.
Frontal and maxillary sinuses non-tender.
Eyes: Normal conjunctivae on inspection. Visual acuity
withSnellen pocket card: OD 20/20, OS
Throat/Neck: Mucous membranes moist. Oropharynx without
erythema, edema, or exudate. No
stridor, no foreignbody. No visible scars,
deformities, or other lesionsonneck inspection.
Trachea is midline and freely
mobile. JVP
Cardiovascular PMI nondisplaced. JVP WNL. No significant change while
standing, squatting, duringValsalva maneuver or
withsustained handgrip.
Chest / Respiratory Thorax atraumatic; no postsurgical scars. Respirations
shallow, normal rate, nonlabored. No
visible bounding of the
chest. No tenderness to chest wall or
vertebralbody palpation. No palpable thrill.
Normal tactile fremitus.
Thorax normal/symmetrical to percussion.
Normal lungs sounds bilaterally.
Abdomen Abdomen atraumatic, obese, nondistended. Normoactive bowel sounds.
No hepatosplenomegaly or palpable masses.
Soft, nontender throughout exam.
Genitourinary / Rectal Normal pelvicexam. No masses or tenderness. Normal
externalgenitalia.
Musculoskeletal /
Osteopathic
Structural
Examination
Normal muscle bulk. No evidence of swelling. calf tenderness or
No inflammatory peripheral edema.
signs.
No
No asymmetry or deformity of the back. No
tenderness or spasm of the paraspinal
muscles.
No localized tenderness of the spinous
processes or pelvic structures.
Neurologic PERRLA.CN II-XII intact.
Psychiatric AOx
Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary
or inguinal chains.
*History of present illness
Patient known to be ischemic heart. Recently he developed retrosternal burning and compressing chest pain, with acute
onset intermittent course for 5 hours. Not radiating , notrelieved by sublingual nitrates , not associated with dyspnea.
there is no history of syncope, palpitation, bluish discoloration of peripheries or lower limboedema.
The pain is not aggravated by chest movement and not relieved by changing posture.
There is no cough, haemoptysis, or audible breathing sounds.
There is no history of dysphagia, odynophagia, hematemesis or heartburn .There is no history of
chest trauma.
There were no symptoms suggesting other systems affection.
*Past History
Patient has history of PCI since 2 years. The patient condition started 3 years ago when he had similar attacks of chest
pain that occurred repeatedly despite receiving sublingual Nitroglycerine tablets. There are no other chronic diseases,
no drug allergy, no history of operations and no blood transfusion
*Family History
There are no chronic disease running in family or similar attacks. Emergency Department
Examination
1ry Survey:
Airway:
The patient has patent airways Breathing:
By Inspection, the Respiratory Rate is 14 breathes / minute, there is symmetrical chestmovements and there is
no chest deformity.
By Palpation, There is no chest tenderness, there is symmetrical chest expansion & there isno shifting of trachea.
By Percussion, No Hyper-resonance
By Auscultation, No Abnormal Breathing sounds.
Circulation:
Central Pulsation is felt, central to peripheral pulsation is comparable &
peripheraltoperipheral pulsation is also comparable.
Radial pulsation is 63 beats per min, regular, of average volume, symmetrical in both sidesand has no special
characters.
Blood Pressure: 115 / 85 mmHg (Normal) Capillary Filling time: less than 2 seconds.
Disability:
The Patient is Alert on AVPU Score.
The pupils are rounded, central, responsive to light & equal on both sides. Exposure:
No apparent injuries in body.
General Examination
Patient is alert , conscious , oriented to time , place and persons , average built , quiet facial expression , no special
decubitus , average intelligence ,he's cooperative
Cardiac Examination
By
inspection:
There is no skin redness, pigmentation, ulceration, fistulae or scars.Respiration is
abdomenothoracic.
No visible pulsation at the apex of the heart.
By Palpation:
Palpable pulsation of the heart at the fifth intercostal space in the midclavicular line.There are no masses,
swellings, tenderness or pulsating masses.
By Auscultation:
No abnormal cardiac sounds, muffling or murmurs were heard at the apex of the heart,xiphisternal area and
aortic areas.
Differential Diagnosis
changing posture.
friction rub on the chest and audible abnormal breathing sounds.
heartburn.
Provisional Diagnosis
A 58 years old male ischemic patient came complaining of intermittent retrosternal sever chest
tightness, with no radiation for 5 hours duration most probably caused by UnStable AnginaPectoris not complicated.
Management
The patient should be admitted and have the following investigations:
The patient should receive:
st
about intake of
sildenafil.
If the patient’s condition improved he should be put under observation for 24 hours.
Drugs taken after stabilization of the condition:
present
Scientific background
Chest pain
Patients with acute no traumatic chest pain are among the most challenging patients cared for by emergency physicians.
They may appear seriously ill or completely well and yet remain at significant risk for sudden death or an acute
myocardial infarction (AMI).
The typical pain of myocardial ischemia has been described as retrosternal or epigastric squeezing, tightening, crushing,