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I- HUMAN CASE STUDY – 69-YEAR-OLD MALE
PRESENTING WITH CHEST PAIN - WEEK #4
(CLASS 6531) SETTING: OUTPATIENT CLINIC
LATEST WITH A SOAP NOTE
1. General Case Information
Case Title & Summary:
A 69-year-old male presents to an outpatient clinic with acute chest pain. This case
emphasizes rapid risk stratification, identification of life-threatening causes of
chest pain, and appropriate escalation of care.
Reason for Encounter:
Evaluation of chest pain
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Patient Demographics:
• Age: 69 years
• Sex: Male
• Height: 5’9” (175 cm)
• Weight: 198 lb (89.8 kg)
• BMI: 29.2 kg/m²
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with limited diagnostic capabilities
(ECG, basic labs)
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“I’ve been having chest pain since this morning.”
3. History of Present Illness (HPI)
The patient is a 69-year-old male who presents with acute onset chest pain that
began approximately 2 hours prior to arrival while walking from his car into a
grocery store. The pain is described as pressure-like and squeezing, located in the
midsternal area, with radiation to the left shoulder and jaw.
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The pain intensity is rated 7/10, persistent, and not relieved by rest. The patient
reports associated shortness of breath, nausea, and diaphoresis. He denies
recent trauma, cough, fever, or upper respiratory symptoms.
He attempted to rest at home but came to the clinic when symptoms did not
resolve.
Aggravating factors:
• Physical exertion
Relieving factors:
• None
Associated symptoms:
• Dyspnea
• Nausea
• Diaphoresis
• Mild lightheadedness
Negative symptoms:
• No syncope
• No palpitations
• No pleuritic pain
• No hemoptysis
Previous episodes:
I- HUMAN CASE STUDY – 69-YEAR-OLD MALE
PRESENTING WITH CHEST PAIN - WEEK #4
(CLASS 6531) SETTING: OUTPATIENT CLINIC
LATEST WITH A SOAP NOTE
1. General Case Information
Case Title & Summary:
A 69-year-old male presents to an outpatient clinic with acute chest pain. This case
emphasizes rapid risk stratification, identification of life-threatening causes of
chest pain, and appropriate escalation of care.
Reason for Encounter:
Evaluation of chest pain
,2|Page
Patient Demographics:
• Age: 69 years
• Sex: Male
• Height: 5’9” (175 cm)
• Weight: 198 lb (89.8 kg)
• BMI: 29.2 kg/m²
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with limited diagnostic capabilities
(ECG, basic labs)
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“I’ve been having chest pain since this morning.”
3. History of Present Illness (HPI)
The patient is a 69-year-old male who presents with acute onset chest pain that
began approximately 2 hours prior to arrival while walking from his car into a
grocery store. The pain is described as pressure-like and squeezing, located in the
midsternal area, with radiation to the left shoulder and jaw.
, 3|Page
The pain intensity is rated 7/10, persistent, and not relieved by rest. The patient
reports associated shortness of breath, nausea, and diaphoresis. He denies
recent trauma, cough, fever, or upper respiratory symptoms.
He attempted to rest at home but came to the clinic when symptoms did not
resolve.
Aggravating factors:
• Physical exertion
Relieving factors:
• None
Associated symptoms:
• Dyspnea
• Nausea
• Diaphoresis
• Mild lightheadedness
Negative symptoms:
• No syncope
• No palpitations
• No pleuritic pain
• No hemoptysis
Previous episodes:
