Exam (elaborations)
FLORENCE BLACKMAN IHUMAN CASE STUDY CHEST PAIN
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FLORENCE BLACKMAN IHUMAN CASE STUDY CHEST PAIN
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, VERSION 1Florence 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?
1
, -
- 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?
2
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