I HUMAN CASE STUDY (WEEK 7) FOR A 49 - YEAR OLD PATIENT REASON FOR ENCOUNTER; INTERMITTEN, Lab Reports of Integrated Case Studies

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I HUMAN CASE STUDY (WEEK 7) FOR A 49 -

YEAR OLD PATIENT REASON FOR

ENCOUNTER; INTERMITTENT SQUEEZ ING

CHEST PAIN || ACTUAL COMPREHENSIVE

CASE STUDY (RESEARCH ANALYSIS AND

RESULTS) LATEST AND COMPLETE VERSION

2024 - 2025 ALREADY GRADED A+||

The following table summarizes your performance on each section of the case, whether you

completed that section or not.

Time spent: 1dy 13hr 58min 29sec Status: Submitted

Case Section Status

Your

Score

Time spent

Performance Details

History Done 63% 12hr

5m

i n 12sec

correct, 13 missed

relative

60 questions asked,22 to

the case's list

Physical exams Done 83%

13hr

52mi

n

55se

c

53 exams 19 1

to the performed,

partially correct,

case's list

0 correc

t, missed

relative

Key

findin gs

organization

Done

34min

40sec

14 findings listed; 16 listed by the case

Problem

stateme

nt

Done 1hr

9m

i n 29sec

150 words long; the case's was 117 words

Differentials Done 88%

13min

14sec

correct, 1

13 items in DDx, 7

misse relativ

the to

the case's list d

e

Differenti

als

ranking

Done 88%

(lead/a

lt

score)

88%

(must

not

miss

score)

7mi

n

38se

c

Tests Done 89%

50min

23sec

10 tests

relativ e

ordere

d, to 8 the correct,

1 case's

list

missed

Diagnosis Done 100% 21sec

Manageme

nt plan

Done

46min 0sec

1645 words long; the case's was 79 words

Exercises Done

68%

(of

scored

items

only)

32mi

n

51se

c

3 of 5 (of scored items only)

correct

1 partially correct

AA

History Notecard 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 details in the appropriate

column "OLDCARTS". Capture the and row.

3. Review your findings and consider possible diagnoses that may correlate with these

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

through back

Duration

Characteristics worsens with deep inspiration

Aggravating worsens when

down, moving, and

breathing

laying

Relieving eased pain when forward leaning

Timing

Treatments

/

Severity 8/

History of Present Illness

Category Data entered by AA

Reason for Encounter Chest

pain

Histor

y

of presen illness

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

y

relieved by sitting

partiall

up and leaning

forward.

She

s

mild nausea

report without

vomiting, denies

fever/chills,

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

e,

extremity/catheterization site or swelling. She reports

pain

compliance with her antiplatelet medications (ASA

and clopidogrel), pantoprazole, and aspirin since

discharge. On exam, patient is febrile, shallow

respirations at norma

l

rate, low-normal oxygen

saturation, and has pericardial friction rub. PMH

is significant for hypertension, tobacco

hyperlipidemi a,

abuse, obesity, and

type-2 diabetes.

family history of heart attack and

Category

Data entered by AA

Past Medical History

Category

Data entered by

AA

Past Medical History Hypertension Hyperlipidemia

Hospitalizations / SurgeriesAcute inferolateral wall ST-elevation myocardial infarction with

PCI/stenting of the righ t coronary

artery

(RCA).

Balloo angioplasty of

n

the left circumflex artery.

Medications

Category Data entered

by

A

A

Medications Clopidogrel 75 mg QD

Atorvastatin 80 mg QD at bedtime

Pantoprazole 40 mg

QD

Aspirin 81 mg QD

Allergies

Category Data entered by AA

Allergies Bactrim (rash)

Preventive Health

Category

Data

entered by AA

Preventive health Up to date

immuniz

atio n

including flu shots

annually. Reports gynecology

normal.

exam was

Family History

Mothe - Type 2 Diabetes r

Family History Fathe

r

• Heart attack, 59 years old

Social History

Category

Data entered 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 fatigued. Laying still to avoid movement, y

breathing slowly.

Integume

ntar / y

Brea

st Warm skin; no significant diaphoresis.

HEENT / Neck Denies any problems night vision, hearing

problems,

ic

with headaches, double vision, difficulty with

problems, ear pain, sinus

sore or difficulty swallowing.

chron throat

s,

Cardiovascular Chest pain. Heart attack 10 days ago.

Denies history of irregular heartbeats palpitations. nor Hypertension

Hyperlipidemia

Respiratory Denies wheezing and production. sputu

m

Gastrointestinal Report mild nausea and reflux. s

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

Musculoskeletal

Denies chest injury. No problems

with muscle and s

joints.

Allergic / Immunologic

Endocrine Denies problems with heat or cold intolerance, increased

thirst,

Sister - Type 2 Diabetes

increased sweating, frequent urination, change in or appetite.

Hematologic /

Lympha

tic

No reports of bruising, bleeding nose bleeds, gums, sites of increased bleeding. or other

Neurologic Denies dizziness, seizures, numbness, or weakness.

Psychiatric Report nervousness

s

due to chest pain.

Physical Exams

Category

Data entered by AA

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 ridgin

t g,

pitting or

,

peeling.

Capillary refill < 2 sec.

Quincke’s Blanching observed.

Test:

HEENT / Neck Head: Normocephalic, atraumatic, no deformities, facial

Cardiovascular

Chest / Respiratory

Abdomen

Genitourinary / Rectal

Musculoskeletal /

Osteopathic

Structural

Examination

features symmetric.Temporal arteries non-tender to

palpation.

Frontal and maxillary sinuses non-tender.

Eyes: Normal conjunctivae on inspection. Visual acuity

with Snellen pocket card: OD 20/20, OS

20/20.

Throat/Neck: Mucous membranes moist. Oropharynx without erythema,

edema, or exudate. No stridor, no foreign body. No visible scars,

deformities, or other lesions on neck inspection. Trachea is midline

and freely

mobile. JVP

WNL

PMI nondisplaced. JVP WNL. No significant change while

standing, squatting, duringValsalva maneuver or with

sustained handgrip.

Thorax atraumatic; no postsurgical scars. Respirations

shallow, normal rate, nonlabored. No visible bounding of the

chest. No tenderness to chest wall or

vertebral body palpation. No palpable thrill.

Normal tactile fremitus.

Thorax normal/symmetrical to percussion.

Normal lungs sounds bilaterally.

Abdomen atraumatic, obese, nondistended. Normoactive bowel sounds.

No hepatosplenomegaly or palpable masses.

Soft, nontender throughout exam.

Normal pelvic exam. No masses or tenderness. Normal

external genitalia.

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.

l O M oA R c P S D | 4 6 0 2 0 6 7 0

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 , not relieved by sublingual nitrates , not associated with

dyspnea. there is no history of syncope, palpitation, bluish discoloration of peripheries or lower limb oedema.

The pain is not aggravated by chest movement and not relieved by changing posture.

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

A 58 years old male ischemic patient came complaining of intermittent retrosternal sever chest