Florence Blackman (66 y/o female) – Chest Pain Case Study Complete Solution

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?