Full Answer Section

• • Date of Birth: [Date]
  • Date of Presentation: [Date]
• Chief Complaint: “Chest discomfort and fatigue for the past 2 weeks.”
• History of Present Illness:
  • Location: Intermittent chest discomfort described as “pressure” or “tightness” located in the center of the chest.
  • Quality: Dull, achy, non-radiating.
  • Onset: Gradual onset over the past 2 weeks.
  • Duration: Episodes last for 15-30 minutes.
  • Severity: 3/10 on a 0-10 pain scale.
  • Aggravating Factors: Exertion, emotional stress.
  • Relieving Factors: Rest.
  • Associated Symptoms: Fatigue, intermittent shortness of breath, occasional dizziness.
• Medications:
  • Aspirin 81 mg PO daily
  • Atorvastatin 40 mg PO daily
  • Lisinopril 10 mg PO daily
  • Levothyroxine 100 mcg PO daily
• Allergies:
  • Penicillin (rash)
• Past Medical History:
  • Hypertension
  • Hypothyroidism
  • Hyperlipidemia
  • Osteoarthritis
• Past Surgical History:
  • Tonsillectomy and adenoidectomy as a child
  • Hysterectomy 5 years ago
• Family History:
  • Mother: History of myocardial infarction at age 65
  • Father: History of stroke at age 72
• Social History:
  • Non-smoker
  • Occasional alcohol use (1-2 glasses of wine per week)
  • Sedentary lifestyle
  • Retired
  • Lives alone
• Review of Systems:
  • General: Fatigue, occasional dizziness.
  • Cardiovascular: Chest discomfort as described above, palpitations.
  • Respiratory: Shortness of breath on exertion.
  • Gastrointestinal: Occasional constipation.
  • Neurological: No headache, numbness, or weakness.
  • Musculoskeletal: Occasional joint pain.
  • Psychosocial: Mild anxiety, occasional feelings of loneliness.

Slide 3: Objective Data

• Vital Signs:

  • Temperature: 98.6°F (37°C)
  • Pulse: 82 beats/min, regular
  • Blood Pressure: 138/88 mmHg
  • Respirations: 18 breaths/min
  • Oxygen Saturation: 98% on room air

• Physical Examination:

  • General: Appears age-appropriate, alert, and oriented.
  • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
  • Respiratory: Clear to auscultation bilaterally.
  • Abdomen: Soft, non-tender, non-distended.
  • Neurological: Cranial nerves intact, no focal neurological deficits.
  • Extremities: No edema.

• Laboratory Data:

  • Complete Blood Count (CBC): Within normal limits.
  • Basic Metabolic Panel (BMP): Within normal limits.
  • Lipid Panel: Total cholesterol: 210 mg/dL, LDL-cholesterol: 140 mg/dL, HDL-cholesterol: 45 mg/dL, Triglycerides: 150 mg/dL.
  • Troponin I: Pending
  • ECG: Sinus rhythm, ST-T wave changes suggestive of ischemia.

Slide 4: Assessment

• Differential Diagnosis:

  • Acute Coronary Syndrome (ACS): Unstable angina, non-ST-elevation myocardial infarction (NSTEMI)
  • Anxiety
  • Gastroesophageal Reflux Disease (GERD)
  • Costochondritis

• Primary Diagnosis:

  • Suspected Acute Coronary Syndrome (NSTEMI)

Slide 5: Plan

• Laboratory and Diagnostic Tests:

  • Troponin I: Serial measurements (at presentation and 3-6 hours later).
  • Electrocardiogram (ECG): 12-lead ECG.
  • Cardiac enzymes: Creatine kinase (CK) and CK-MB.
  • Complete Blood Count (CBC) with differential.
  • Comprehensive Metabolic Panel (CMP).
  • Cardiac biomarkers: B-type natriuretic peptide (BNP).

• Pharmacologic Treatment:

  • Aspirin 325 mg PO chewable immediately.
  • Clopidogrel 300 mg PO loading dose, then 75 mg PO daily.
  • Low-molecular-weight heparin (enoxaparin) subcutaneous injection.
  • Nitroglycerin sublingual as needed for chest pain.

• Non-pharmacologic Treatment:

  • Bed rest with continuous cardiac monitoring.
  • Oxygen therapy as needed to maintain oxygen saturation above 94%.

• Anticipatory Guidance:

  • Instruct the patient to contact emergency services immediately if chest pain worsens or if she experiences shortness of breath, dizziness, or fainting.
  • Emphasize the importance of adhering to the prescribed medications.
  • Discuss lifestyle modifications, including smoking cessation, dietary changes (low-fat, low-sodium diet), regular exercise, and stress management techniques.