IHuman Case Study: Florence Blackman (1 Solved Case)

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Florence Blackman Ihuman Case Study 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

VERSION 1
Florence Blackman (66 y/o female) – Chest Pain
• CC: Intermittent squeezing 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 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

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• CC: Fatigue, SOB, productive cough with yellow/green sputum
• MSAP: Hypoxia
• Tachypnea, dyspnea
• Fever and chills
• Fatigue and myalgia
• Right-sided chest wall pain aggravated by coughing
• Productive cough
• Right middle and lower lung crackles
• Bilateral cervical lymphadenopathy
• Tachycardia
• Previous hx of the flu 2 weeks ago, but got better
• Childhood asthma per history
History Questions:
- How can I help you today?
- Any other symptoms or concerns we should discuss?
- Do you have any allergies?
- Are you taking any prescription medications?
- Are you taking any OTC or herbal medications?
- How high is your fever?
- When did your cough start? – 4 days ago
- Is there a pattern to your cough? – no
- Does anything make your cough better or worse?
- Are you coughing up any sputum? – yellowish green stuff
- What are the events surrounding the start of your cough? – symptoms started without
much warning, thought maybe just got tired going to the party, but got worse over time
- What treatments have you had for your cough? – cough syrup, doesn’t help
- Do you awaken at night coughing? – yes, can’t sleep
- Have you had a cough like this before? – no
- Do you have any pain in your chest? – yes, here on the right side when I cough or take a
deep breath (points to right thorax, 6-8th intercostal space at midaxillary line)
- How severe (1-10 scale) is the pain in your chest? – 7-8 when cough or deep breathe
- Have you had any contact with other sick people? – no
- Tell me about any current or past medical problems? – none besides mild asthma
- Any previous medical, surgical, or dental procedures? – none besides fillings in teeth
- Have you ever been hospitalized? – no
- Do you have any of the following problems: fatigue, difficulty sleeping, unintentional
weight loss or gain, fevers, night sweats? – “some of that stuff for sure”

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