I HUMAN CASE STUDY – 69-YEAR-OLD MALE PRESENTING WITH CHEST PAIN - WEEK #4 (CLASS 6531) SETTING: OUTPATIENT CLINIC LATEST WITH A SOAP NOTE

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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
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Case Title & Summary:
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A 69-year-old male presents to an outpatient clinic with acute chest pain. This
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case emphasizes rapid risk stratification, identification of life-threatening
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g; causes of chest pain, and appropriate escalation of care.
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Reason for Encounter:
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Evaluation of chest pain
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Patient Demographics: g;




• Age: 69 years g; g;



• Sex: Male g;



• Height: 5’9” (175 cm) g; g; g;



• Weight: 198 lb (89.8 kg) g; g; g; g;



• BMI: 29.2 kg/m² g; g;




Case Mode: Learning mode
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Case Location: Outpatient primary care clinic with limited diagnostic capabilities
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g; (ECG, basic labs) g; g;




Attempts Allowed: Unlimited g; g;




2. Chief Complaint (CC) g; g;




“I’ve been having chest pain since this morning.”
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3. History of Present Illness (HPI) g; g; g; g;




The patient is a 69-year-old male who presents with acute onset chest pain
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g; that began approximately 2 hours prior to arrival while walking from his car
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g; into a grocery store. The pain is described as pressure-like and squeezing,
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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
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g; reports associated shortness of breath, nausea, and diaphoresis. He denies
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g; recent trauma, cough, fever, or upper respiratory symptoms.
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He attempted to rest at home but came to the clinic when symptoms did not
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resolve.
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Aggravating factors: g;




• Physical exertion g;




Relieving factors: g;




• None

Associated symptoms: g;




• Dyspnea
• Nausea
• Diaphoresis
• Mild lightheadednessg;




Negative symptoms: g;




• No syncope g;



• No palpitations
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• No pleuritic pain
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• No hemoptysis
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Previous episodes: g;