From Symptom To Diagnosis: Comprehensive Outpatient Evaluation

FROM SYMPTOM TO DIAGNOSIS: COMPREHENSIVE OUTPATIENT EVALUATION OF CHEST PAIN IN A 69-YEAR-OLD WOMANPatient Name: Patient Name Eleanor "Ella" M. Harrison Demographics: Age: 69 years Gender: Female Ethnicity: Caucasian Marital Status: Married Occupation: Retired librarian Living Situation: Lives with spouse 1 Reason for Encounter Primary Complaint: Chest pain (CLASS 6531) Location: Outpatient clinic with X-ray, ECG, and laboratory capabilities Duration: 2-3 hours (acute onset today) Character: Retrosternal, pressure-like, radiates to left arm Associated with mild shortness of breath and diaphoresis Aggravating Factors: Exertion (walking upstairs) Relieving Factors: Rest slightly improves painAssociated Symptoms: Nausea Mild dizziness No palpitations reported 2 Past Medical History Hypertension (20 years) Type 2 Diabetes Mellitus (15 years) Hyperlipidemia Osteoarthritis 3 Surgical History Cholecystectomy (age 50) 4 Medications Metformin 500 mg BID Lisinopril 10 mg daily Atorvastatin 20 mg daily Aspirin 81 mg daily Occasional acetaminophen for arthritis 5 Allergies Penicillin (rash)6 Family History Father: Myocardial infarction at age 72 Mother: Hypertension and Type 2 diabetes 7 Social History Non-smoker Rare alcohol (1 glass wine/week) No recreational drug use Moderate physical activity (walking) 8 Review of Systems (ROS) System Findings Cardiac Chest pressure, mild SOB Respiratory No cough, no wheezing GI Nausea, no vomiting Neuro Dizziness, no