Florence Blackman (66 y/o female) – Chest Pain
• CC: Intermittent squeezing chest pain
• MSAP: Exertional “squeezing” mid-chest pain radiatin
... [Show More] g 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 other symptoms we should discuss?
- Do you have any allergies?
- Are you taking any OTC or herbal medications?
- Any new or recent changes in medications?
- What does the 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?
- Does the pain in your chest radiate someplace else? Where?
- Do you have unusual heartbeats (palpitations)?
- Does the pain get worse with breathing?
- Does your pain awaken you from your sleep?
- 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 your shortness 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?
- Do you have problems with: N/V, constipation, diarrhea, coffee grounds in 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 sports that 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.
- Stress test: 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 needs improvement 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 workouts for next 3 months
o D/c alcohol for next 2 months as starts a statin
- f/u in 3-4 weeks
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