1|Page
WEEK 4 IHUMAN CASE ANALYSIS — 69-YEAR-
OLD MALE PRESENTING WITH CHEST PAIN
(CLASS 6531) LOCATION: OUTPATIENT CLINIC
LATELY UPDATE QUESTIONS AND COMPLETE
VERSION WITH A SOAP NOTE
,2|Page
1. General Case Information
Case Title & Summary:
This case examines a 69-year-old male presenting to an outpatient clinic with
chest pain. The case focuses on rapid identification of life-threatening causes of
chest pain, differentiation between cardiac and non-cardiac etiologies,
appropriate diagnostic evaluation, and timely escalation of care.
Reason for Encounter:
Evaluation of new-onset chest pain.
Patient Demographics:
Age: 69 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 198 lb (90 kg)
BMI: 29.2 kg/m² (overweight)
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with ECG capability and STAT lab
access
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
, 3|Page
Patient states:
“I’ve been having chest pain for the past few hours.”
Location: Central chest
Onset: Sudden onset earlier today
Duration: Intermittent over 4 hours
Character: Pressure-like, squeezing sensation
Severity: 7/10
Radiation: Left shoulder and jaw
Timing: Occurs with exertion, improves with rest
Associated symptoms: Shortness of breath, diaphoresis
3. History of Present Illness (HPI)
The patient is a 69-year-old male who presents with acute chest pain that began
approximately 4 hours prior to arrival while walking up a slight incline. He
describes the pain as a substernal pressure that radiates to the left shoulder and
jaw, lasting about 10–15 minutes per episode and partially relieved by rest.
He reports associated shortness of breath, nausea, and diaphoresis during the
episodes. The pain recurred twice with minimal exertion and prompted him to seek
medical attention.
He denies trauma, fever, cough, hemoptysis, syncope, palpitations, or recent
illness. No similar episodes of this intensity in the past, though he reports
occasional exertional chest tightness over the last several months that resolved
quickly with rest.
WEEK 4 IHUMAN CASE ANALYSIS — 69-YEAR-
OLD MALE PRESENTING WITH CHEST PAIN
(CLASS 6531) LOCATION: OUTPATIENT CLINIC
LATELY UPDATE QUESTIONS AND COMPLETE
VERSION WITH A SOAP NOTE
,2|Page
1. General Case Information
Case Title & Summary:
This case examines a 69-year-old male presenting to an outpatient clinic with
chest pain. The case focuses on rapid identification of life-threatening causes of
chest pain, differentiation between cardiac and non-cardiac etiologies,
appropriate diagnostic evaluation, and timely escalation of care.
Reason for Encounter:
Evaluation of new-onset chest pain.
Patient Demographics:
Age: 69 years
Sex: Male
Height: 5’9” (175 cm)
Weight: 198 lb (90 kg)
BMI: 29.2 kg/m² (overweight)
Case Mode: Learning mode
Case Location: Outpatient primary care clinic with ECG capability and STAT lab
access
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
, 3|Page
Patient states:
“I’ve been having chest pain for the past few hours.”
Location: Central chest
Onset: Sudden onset earlier today
Duration: Intermittent over 4 hours
Character: Pressure-like, squeezing sensation
Severity: 7/10
Radiation: Left shoulder and jaw
Timing: Occurs with exertion, improves with rest
Associated symptoms: Shortness of breath, diaphoresis
3. History of Present Illness (HPI)
The patient is a 69-year-old male who presents with acute chest pain that began
approximately 4 hours prior to arrival while walking up a slight incline. He
describes the pain as a substernal pressure that radiates to the left shoulder and
jaw, lasting about 10–15 minutes per episode and partially relieved by rest.
He reports associated shortness of breath, nausea, and diaphoresis during the
episodes. The pain recurred twice with minimal exertion and prompted him to seek
medical attention.
He denies trauma, fever, cough, hemoptysis, syncope, palpitations, or recent
illness. No similar episodes of this intensity in the past, though he reports
occasional exertional chest tightness over the last several months that resolved
quickly with rest.
