iHuman Comprehensive Case Study Week 4: 69-Year-Old Male
Presenting With Chest Pain – Expert Evaluation in Outpatient Clinic
(Class 6531)
This iHuman Week 4 case study analyzes a 69-year-old male presenting with chest pain in an outpatient clinic
setting. The case includes detailed clinical assessment, differential diagnosis, diagnostic evaluation, and
evidence-based management strategies for adult patients with cardiac and non-cardiac chest pain.
iHuman Week 4 case study,
69-year-old male chest pain,
adult cardiac assessment,
outpatient chest pain evaluation,
,Patient Overview
Name: Not specified (iHuman case)
Age: 69 years
Gender: Male
Presenting Complaint: Chest pain
Clinical Setting: Outpatient clinic with diagnostic and laboratory capabilities
Reason for Visit:
The patient reports onset of chest pain, described as pressure-like, intermittent, and radiating to the left arm. He
is seeking evaluation in an outpatient clinic for assessment, differential diagnosis, and management.
,SOAP Note
S – Subjective
Chief Complaint (CC):
“I have been experiencing chest pain on and off for the past few hours.”
History of Present Illness (HPI):
• Onset: Sudden onset 3–4 hours ago
• Location: Substernal, radiates to left arm and jaw
• Duration: Each episode lasts 10–15 minutes
• Character: Pressure-like, tightness
• Associated Symptoms: Shortness of breath, diaphoresis, mild nausea
• Aggravating Factors: Physical exertion
• Relieving Factors: Rest
• Severity: 7/10 on pain scale
Past Medical History (PMH):
• Hypertension
• Hyperlipidemia
• Type 2 Diabetes Mellitus
• No prior myocardial infarctions reported
Past Surgical History (PSH):
• None reported
Medications:
• Metformin 500 mg PO BID
• Lisinopril 10 mg PO daily
• Atorvastatin 20 mg PO daily
Allergies:
• NKDA
Family History:
• Father had coronary artery disease, MI at age 65
• Mother with hypertension
Social History:
, • Retired
• Denies tobacco or illicit drug use
• Occasional alcohol
• Sedentary lifestyle
Review of Systems (ROS):
• Cardiovascular: Positive for chest pressure, palpitations
• Respiratory: Shortness of breath on exertion
• GI: Mild nausea, no vomiting
• Neurological: No syncope or dizziness
• General: Fatigue, mild diaphoresis
O – Objective
Vital Signs:
• BP: 150/90 mmHg
• HR: 98 bpm
• RR: 20/min
• Temp: 98.4°F
• SpO₂: 95% on room air
General Appearance:
• Mild distress, alert, oriented x3
Cardiovascular Exam:
• Regular rhythm, no murmurs, rubs, or gallops
• Peripheral pulses intact
• Jugular venous distention absent
Respiratory Exam:
• Lungs clear to auscultation bilaterally
• No wheezes or crackles
Abdomen:
• Soft, non-tender, no hepatosplenomegaly
Extremities:
Presenting With Chest Pain – Expert Evaluation in Outpatient Clinic
(Class 6531)
This iHuman Week 4 case study analyzes a 69-year-old male presenting with chest pain in an outpatient clinic
setting. The case includes detailed clinical assessment, differential diagnosis, diagnostic evaluation, and
evidence-based management strategies for adult patients with cardiac and non-cardiac chest pain.
iHuman Week 4 case study,
69-year-old male chest pain,
adult cardiac assessment,
outpatient chest pain evaluation,
,Patient Overview
Name: Not specified (iHuman case)
Age: 69 years
Gender: Male
Presenting Complaint: Chest pain
Clinical Setting: Outpatient clinic with diagnostic and laboratory capabilities
Reason for Visit:
The patient reports onset of chest pain, described as pressure-like, intermittent, and radiating to the left arm. He
is seeking evaluation in an outpatient clinic for assessment, differential diagnosis, and management.
,SOAP Note
S – Subjective
Chief Complaint (CC):
“I have been experiencing chest pain on and off for the past few hours.”
History of Present Illness (HPI):
• Onset: Sudden onset 3–4 hours ago
• Location: Substernal, radiates to left arm and jaw
• Duration: Each episode lasts 10–15 minutes
• Character: Pressure-like, tightness
• Associated Symptoms: Shortness of breath, diaphoresis, mild nausea
• Aggravating Factors: Physical exertion
• Relieving Factors: Rest
• Severity: 7/10 on pain scale
Past Medical History (PMH):
• Hypertension
• Hyperlipidemia
• Type 2 Diabetes Mellitus
• No prior myocardial infarctions reported
Past Surgical History (PSH):
• None reported
Medications:
• Metformin 500 mg PO BID
• Lisinopril 10 mg PO daily
• Atorvastatin 20 mg PO daily
Allergies:
• NKDA
Family History:
• Father had coronary artery disease, MI at age 65
• Mother with hypertension
Social History:
, • Retired
• Denies tobacco or illicit drug use
• Occasional alcohol
• Sedentary lifestyle
Review of Systems (ROS):
• Cardiovascular: Positive for chest pressure, palpitations
• Respiratory: Shortness of breath on exertion
• GI: Mild nausea, no vomiting
• Neurological: No syncope or dizziness
• General: Fatigue, mild diaphoresis
O – Objective
Vital Signs:
• BP: 150/90 mmHg
• HR: 98 bpm
• RR: 20/min
• Temp: 98.4°F
• SpO₂: 95% on room air
General Appearance:
• Mild distress, alert, oriented x3
Cardiovascular Exam:
• Regular rhythm, no murmurs, rubs, or gallops
• Peripheral pulses intact
• Jugular venous distention absent
Respiratory Exam:
• Lungs clear to auscultation bilaterally
• No wheezes or crackles
Abdomen:
• Soft, non-tender, no hepatosplenomegaly
Extremities:
