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Case 12: Chest pain Last updated: October 7, 2022

Examinee instructions

Opening scenario

Hazel Porter, a 35-year-old female; , comes to the emergency department because of chest pain.

Vital signs

Temperature: 100.4°F (38°C)

Blood pressure: 110/65 mm Hg

Heart rate: 105/min

Respirations: 30/min

Examinee tasks

Take a focused history.

Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).

Explain the preliminary differential diagnoses and initial workup plan to the patient.

Write the patient notes after leaving the room.

Patient encounter

Focused history

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History of present illness

Chief complaint

My chest hurts.

Location

It is difficult to say exactly, but I think it is on the left side.

Intensity (on a scale from 0–10)

It is a 5.

Quality

It feels like my chest is really tight and then there is a stabbing pain, too.

Onset

It started suddenly this morning after I got out of bed.

Precipitating events

I do not think so. I was asleep before it started.

Progression/constant/intermittent

It is getting worse.

Previous episodes

No.

Radiation

No, it is just in my chest.

Alleviating factors

Sitting up makes it a little bit better.

Aggravating factors

The stabbing pain gets worse every time I breathe in.

Associated symptoms

I have a hard time breathing.

Review of systems specific to chest pain and shortness of breath

Trauma

No.

Recent travel

I was in Japan; for the past 2 weeks. I just got back last night.

Swelling of the ankles

My legs felt swollen on the flight back, but they always swell up on the plane, so I did not think anything of it.

Nausea/vomiting

No.

Fever/chills

I did not take my temperature, but I have been having chills for the past few days.

Fatigue

I have been really tired with all the traveling over the past 2 weeks.

Racing of the heart

Yes, since this morning.

Rash/skin changes

No.

Cough

I have had a cough since last week, but it feels even worse today.

Productive

No.

Blood

No.

Recent infections

Just the cold I got last week in Japan.

Dizziness

A little bit if the pain gets really bad.

Leg pain

My right leg hurts right now. But my entire body has been achy for the past few days.

Past medical history, family history, and social history

Past medical history

None.

Allergies

None.

Medications

I take a birth control pill and a daily multivitamin.

Hospitalizations

Never.

Ill contacts

No.

Past surgical history

None.

Family history

My mom died of a heart attack when she was 40 years old. And my grandma also had a heart attack when she was young, but I do not remember how old she
was exactly.

Work

I am in charge of buying for a large online retailer. That is why I was in Japan.

Home

I live by myself.

Alcohol

Not much. Sometimes on the weekends if I go out to dinner with my friends.

Recreational drugs

Never.

Tobacco

Yes. I smoke about 2 packs a day. I think I started when I was about 15 years old.

Exercise

No.

Diet

I eat out a lot – BBQ, fried chicken, those kind of things. I know that I do not have the healthiest diet.

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Focused physical examination

Washed hands

Used respectful draping

Neck examination

Evaluation of JVD

Cardiovascular examination

Palpation of the radial pulse

Auscultation of the heart

Chest examination

Inspection of the chest

Increased respiratory effort (use of accessory muscles of respiration)

Palpation of the chest

Percussion of the lung fields

Auscultation of the lungs

Examination for fremitus

Extremities

Inspection of the lower extremities

Palpation of the lower extremities

Right calf tender to palpation

Homan sign

Positive

Examination for pitting edema

Palpation of pedal pulses

Communication and interpersonal skills

Patient interaction

Examinee knocked on the door.

Examinee introduced him- or herself and identified his/her role.

Examinee correctly used the patient's name.

Examinee asked open-ended questions.

Examinee listened attentively (did not interrupt the patient).

Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).

Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).

Examinee did not repeat painful maneuvers during physical examination.

Examinee discussed initial diagnostic impressions with the patient.

Examinee explained the management plan.

Examinee used non-medical terms and provided reasons for planned steps in management.

Examinee evaluated the patient's agreement with the next diagnostic steps.

Examinee asked about concerns or questions.

Counseling and challenge

Examinee offered counseling on smoking cessation.

Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Ms. Porter, I understand your concern.I am very glad that you decided to see me as soon as your symptoms
started today. Given your family history and your recent long-distance flight, I would like to rule out that you have a blood clot in your heart or
your lungs. I can assure you that we are doing everything in our power to provide you with the best possible care. Once we are done here, we
will give you some oxygen and some pain medication to make breathing a little easier. I would also like to draw some blood, take a look at the
function of your heart, and take some pictures of your lungs. A technician will come in to perform an ECG. This is a way for us to get a better
idea of whether your heart is getting enough oxygen and is moving the way it should. The technician will put little patches on your chest, arms,
and legs and then a machine will read the electrical currents that run through your heart. The test does not hurt and does not take long to do. I
would also like to get a CT, a computed tomography, of your lungs. This test is very quick and provides us with very detailed pictures of your
lungs. It allows us to see if there is a blood clot or an infection there. If anything is unclear at any point while you are here or if you have any
questions or concerns, please make sure to let us know. If you would like to have any friends or family here for support today, we would be more
than happy to contact them for you. Does that all sound okay? Do you have any questions right now?”

Patient note

Further discussion

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