COMPREHENSIVE I HUMAN CASE WEEK #7 49-YEAR OLD PATIENT: INTERMITTENT SQUEEZING CHEST PAIN, Exams of Nursing

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COMPREHENSIVE I HUMAN CASE WEEK #7 49-YEAR

OLD PATIENT REASON FOR ENCOUNTER:

INTERMITTENT SQUEEZING CHEST PAIN LATEST

STUDY CASE ACTUAL SCREENSHOTS NEW!!!!! 2025

Exercises Done 68% (of scored items only)

32min 51sec

3 of 5 correct 1 partially correct

(of scored items only)

AA

HistoryNotecard by AA on case

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms ( Sx ) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.
2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
3. Review your findings and consider possible diagnoses that may correlate with these

symptoms.(Remember to consider the patient's age and risk factors.) Use your ideas to help the case. guide your physical examination in the next section of

HPI Sx = chestpain

Sx

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Sx

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Sx

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Sx

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Sx

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Onset 2.5 hours ago

Location deepin chest, pierces

through back

Duration

Characteristics worsens with deep inspiration

Aggravating worsens when laying

down, moving, and breathing

Relieving eased pain when leaning

forward

Timing /

Treatments

Severity 8/

COMPREHENSIVE I HUMAN CASE WEEK #7 49-YEAR

OLD PATIENT REASON FOR ENCOUNTER:

INTERMITTENT SQUEEZING CHEST PAIN LATEST

STUDY CASE ACTUAL SCREENSHOTS

History of Present Illness

Category Data entered by AA

Reason for Encounter Chest pain

History of present illness 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 partially relieved by sitting up and leaning forward.

She reports mild nausea without vomiting, denies fever/chills,

palpitations, lightheadedness/syncope, SOB, cough, URI, or

extremity/catheterization site pain or swelling. She reports

compliance with her antiplatelet medications (ASA

and clopidogrel), pantoprazole, and aspirin since

discharge. On exam, patient is febrile, shallow

respirations at normal rate, low-normal oxygen

saturation, and has pericardial friction rub. PMH

is significant for hypertension, hyperlipidemia, tobacco

abuse, obesity, and type- 2 diabetes.

family history of heart attack and

Past Medical History

Category Data entered by AA

COMPREHENSIVE I HUMAN CASE WEEK #7 49-YEAR

OLD PATIENT REASON FOR ENCOUNTER:

INTERMITTENT SQUEEZING CHEST PAIN LATEST

STUDY CASE ACTUAL SCREENSHOTS

Category Data entered by AA

General Slightly fatigued. Laying still to avoid movement, breathingslowly.

Integumentary / 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, chronic sore throats, or difficulty swallowing.

Cardiovascular Chest pain. Heart attack 10 days ago.

Denies history of irregular heartbeats nor Hypertension Hyperlipidemia

palpitations.

Respiratory Denies wheezing and sputum production.

Gastrointestinal Reports mild nausea and reflux.

Genitourinary Denies urinary frequency, pain, incontinence, or difficulty.

Musculoskeletal Denies chest injury. No problems with muscles and joints.

Allergic / Immunologic

Endocrine Denies problems with heat or cold intolerance, increasedthirst,

increasedsweating, frequent urination,or change in appetite.

Hematologic / Lymphatic No reports of bruising, bleeding gums, sites of increased bleeding.

nose bleeds, or other

Neurologic Denies dizziness, seizures, numbness, or weakness.

Psychiatric Reports nervousness due to chest pain.

Physical Exams

Category

Data entered by AA

General Obese with a BMI of 29.4.

AOx Skin is dry and febrile. Skin Skin warm and dry with no lesions.

Nails without ridging, pitting, or peeling.

Capillary refill < 2 sec. Quincke’sTest: Blanchingobserved.

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

1. Acute Coronary Syndrome (most probable)
2. Pericarditis excluded by absence of localized friction rub over pericardium.
3. Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.
4. Musculoskeletal Pain excluded by not being aggravated by chest movement and not being

relieved by changing posture.

5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of

cough, haemoptysis, friction rub on the chest and audible abnormal breathing sounds.

6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia,

hematemesis or heartburn.

Provisional Diagnosis

Pulmonary embolism Sudden onset, pleuritic pain, and dyspnea

lOMoARcP SD| 46 020670

Aortic dissection Tearing pain with radiation to back, neurologic symptoms

Pericarditis Positional ache, dyspnea

Pneumothorax Pleuritic pain and dyspnea

Acute coronary syndrome Vague, pressure-like pain, radiation to arm, neck, jaw

Esophageal rupture Constant retrosternal, epigastric pain, history of inciting event

Pneumonia Pleuritic pain, cough, dyspnea, chills

SPECIFIC CAUSES OF CHEST PAIN Angina Pectoris

The pain of chronic stable angina is episodic and lasts 5 to 15 minutes. It is precipitated by exertion and

relieved with rest or sublingual nitroglycerin within 3 minutes. The pain is typically visceral in nature

(aching, pressure, and squeezing), with radiation to the neck, jaw, arm, or hand. In individual patients

the character of each attack varies little with recurrent episodes. Most patients can differentiate their

usual angina from other causes of pain. Physicians evaluating patients with stable angina should screen

carefully for changes in the pattern that would suggest a shift from stable to unstable angina or even

suggest a different diagnosis.

Unstable Angina :

Patients who complain of recent onset of angina, changes in the character of the angina, or angina at

rest are thought to have an unstable pattern of their angina. They are at risk for an AMI or sudden

cardiac death (see Chapter 21 for management).

Variant (Prinzmetal) Angina

This form of angina is thought to be due to spasm of the epicardial vessels in patients with normal coronary

arteries (one third of cases) or in patients with underlying atherosclerotic disease (two thirds of cases). Pain

typically occurs at rest and may be precipitated by the use of tobacco or cocaine. The ECG typically shows

ST- segment elevations during an acute attack. Acute Myocardial Infarction

Ischemic pain that lasts longer than 15 minutes, is not relieved by nitroglycerin, or is accompanied by diaphoresis,

dyspnea, nausea, or vomiting suggests the diagnosis of AMI. The clinician must understand the limitations of the

screening tools used in the ED and should have a high level of suspicion for AMI in patients with risk factors and

prolonged or persistent symptoms for whom there is no other clear diagnosis. Aortic Dissection

This diagnosis should be suspected in the patient who complains of sudden onset of severe, tearing pain in the

retrosternal or midscapular area. High-risk patients are also those at risk for AMI, specifically the middle-age

hypertensive male. The patient may be hypertensive or hypotensive in shock. There may be a diastolic murmur of

aortic regurgitation, indicating a proximal dissection, or distal pulse deficits, indicating a distal dissection. The

dissection may occlude coronary ostia, resulting in myocardial infarction, or the carotids, resulting in cerebral

ischemia and stroke. Chest x-ray, computed tomography, trans esophageal echocardiography (TEE), and

angiography can aid in the diagnosis of this condition. Musculoskeletal Causes

Chest pain due to irritation or inflammation of structures in the chest wall is commonly seen in the ED. Possible

causes include costochondritis, intercostal strain due to severe coughing, and pectoralis muscle strain in the

setting of recent physical exertion. Patients will complain of sharp pain that is worsened with movement of the

chest wall (eg, coughing, and some pain that can be elicited by palpation of the chest wall). These findings in

patients without any other symptoms and no history of significant cardiac disease support the diagnosis of

musculoskeletal pain. This pain is generally responsive to no steroidal anti-inflammatory drugs. It is important to

emphasize that the presence of chest wall tenderness does not rule out the possibility of myocardial ischemia.

lOMoARcP SD| 46 020670

Gastrointestinal Causes

Esophageal reflux, dyspepsia syndromes, and esophageal motility disorders can produce chest pain that is difficult

to distinguish from ischemic pain. Patients may complain of burning, gnawing pain associated with an acid taste

radiating into the throat. Pain may be exacerbated by meals, worsen when supine, and may be associated with

belching. Clinicians should determine whether the symptoms are due to a GI disorder based on the clinical

presentation and the absence of findings and/or risk factors suggesting an ischemic cause. Diagnostic decisions

should not be made on the basis of a response to a therapeutic trial of antacids, GI cocktails, or nitroglycerin.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

Assume that every patient complaining of chest pain might be having an AMI.

Patients with suspicious histories should have large-bore IV line established, a cardiac monitor,

supplemental O 2 , and ECG obtained as soon as possible. Vital signs and pulse oximetry should be

monitored continuously.

Ask patients about cardiac risk factors, preexisting coronary artery disease, quality of chest pain, time

of onset and duration of symptoms, and whether the pattern has been stable, unstable, continuous, or

intermittent. Ask specifically for clues to noncardiac causes of chest pain: ability to elicit pain by

movement or cough; the relation of pain to meals; or pain that is of sudden onset, referred to the back,

or pleuritic in nature.

Examine patients while noting evidence of heart failure or valvular insufficiency, pericardial rubs, or

tenderness of the chest wall. Specifically, physicians should ask whether pain elicited on palpation of

the chest wall exactly reproduces the patient's pain.

An ECG should be obtained on all patients for whom there is a reasonable suspicion of myocardial

ischemia. A normal ECG, although minimizing the likelihood of an AMI, does not definitively rule out the

possibility of MI.

If the etiology of chest pain remains unclear in some patients, clinicians should consider more

diagnostic tests as guided by clinical suspicion and findings.

Clinicians should not use patients' clinical response to GI cocktails, nitroglycerin, or NSAIDs to exclude

the possibility of myocardial ischemia.

In patients with nondiagnostic ECGs for whom there is a clinical suspicion for ischemia, clinicians should

consider provocative testing, echocardiography, or admission and observation. Physicians should not

rely on serum enzyme testing to rule out the possibility of clinically significant disease.