Florence Blackman 66 Year-old Female – Chest Pain 2 DIFFERENT VERSIONS OF THE ANSWER EXPERT FEEDBACK (SOLUTIONS)

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

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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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