Question

1. A 58-year old male presents with a complaint of severe chest pain over the past hour. He did not call 911 “because I don’t have the money for an ambulance.”

• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list:
  • Pertinent positive and negative information
  • Differential and working diagnosis
  • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

1. questions could be asked:

• where is the pain?
• what provoked the pain?
• what makes the pain worsen? or better?
• did the pain occur in rest or during the activity?
• does it relieve on repositioning?
• duration of pain?
• how bad it is?
• have you taken any medicine to relieve the pain?
• history of heart disease?

2. physical examination:

• review the vital signs
• look for tracheal deviation
• check for jugular vein dilation, tamponade.
• check for respiratory muscle usage
• chest wall expansion, lesions,
• palpate for local tenderness etc..
• cardiac examinations.

3. further testing:

• ECG
• biomarkers
• CT scan, X-RAY

4. SOAP format:

S-subjective data: patient complaints about chest pain, tightness, shortness of breath, dizziness, etc... (positive information)

marriage, child, workload, fracture, etc,, (negative information)

O. objective data: vital signs, physical examinations, imaging results, and other lab results.

A- assessment: severe chest pain

differential diagnosis:

cardiac: MI, myocarditis, mitral valve prolapse, Angina, etc...

P- plan:

administrate O₂ therapy, consider nitroglycerin, administer aspirin, opioid administration

health education:

avoid smoking, advise for regular follow up, advise to reduce anxiety.