I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
Week 7 I-Human
CASE
I-HUMAN PATIENTS CASE STUDY: ASSESSING THE
CARDIOVASCULAR SYSTEM
Case Title: Exertional Chest Pressure in a Patient with Multiple
Risk Factors
Patient: Eleanor Vance
Age: 68 years
Gender: Female
I-HUMAN PATIENTS CASE STUDY:
Race/Ethnicity: Non-Hispanic White
ASSESSING THE CARDIOVASCULAR SYSTEM
Setting: Outpatient Primary Care Clinic (follow-up visit for hypertension management)
Date of Encounter: March 15, 2026
1. Chief Complaint (Presenting Problem)
“I’ve been feeling a heavy, uncomfortable pressure right in the middle of my chest when I
walk up the hill to my mailbox. It goes away after I sit down and rest for a few minutes.
But yesterday, it lasted longer and felt a bit worse than before.”
, I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
Duration: Intermittent symptoms for 3 weeks, with a notable worsening episode 24
hours prior to presentation.
Student Note: The patient’s description of “pressure” rather than sharp or stabbing
pain, the relationship to exertion, and the relief with rest are classic for angina pectoris.
The recent worsening (increased duration and intensity) raises concern for possible
progression to unstable angina or an acute coronary syndrome (ACS) , even if the
pattern remains largely exertional.
2. History of Presenting Illness (HPI) – Expanded with
Clinical Pearls
The student must systematically characterize the symptom using the OLDCARTS
mnemonic, but also explore risk factors, associated symptoms, and medication
history (including potential inappropriate use of others’ medications).
Onset
• First noticed approximately 3 weeks ago while gardening (pulling weeds,
bending, light exertion). Initially dismissed as “muscle strain” or “indigestion.”
• Most concerning episode occurred yesterday at 7:00 PM while cooking dinner
(standing, stirring, minimal exertion compared to gardening). This episode was
different: longer duration and accompanied by mild nausea.
Location
• Substernal, central chest – patient points to the middle of the sternum with a
closed fist (positive Levine’s sign).
Clinical pearl: Levine’s sign (clenched fist over sternum) is highly suggestive of
ischemic cardiac pain.
• No radiation to jaw, neck, left shoulder/arm, or back.
Note: Absence of radiation does NOT rule out angina; many patients, especially
women and diabetics, have atypical or no radiation.
, I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
Duration
• Typical episodes: 2–3 minutes after stopping exertion.
• Yesterday’s episode: 10 minutes (even after stopping activity and sitting down).
This is a red flag – prolonged duration suggests possible unstable angina or non-
ST-elevation myocardial infarction (NSTEMI).
Character
• “Heavy,” “tight,” “like a vise grip” or “someone sitting on my chest.”
• Denies sharp, stabbing, burning, or pleuritic quality.
Pleuritic pain (worse with deep breath) would suggest pericarditis, pneumothorax,
or pulmonary embolism – not typical for stable angina.
Aggravating Factors
• Exertion: Walking >100 yards (especially uphill), climbing one flight of stairs,
heavy housework (mopping, carrying groceries).
• Emotional stress: Arguments with her husband (“when we fight, I feel it in my
chest”).
• Cold weather: Walking outside in winter air triggers symptoms more quickly.
Mechanism: Cold exposure increases systemic vascular resistance and myocardial
oxygen demand.
• Large meals: Eating a heavy dinner (especially high-fat) may provoke symptoms
30–60 minutes later – postprandial angina due to splanchnic shunting of blood.
Relieving Factors
• Rest: Sitting or lying down for 2–3 minutes consistently relieves typical episodes.
• Nitroglycerin: She took one of her husband’s nitroglycerin tablets (0.4 mg
sublingual) during yesterday’s episode. Pain improved within 3 minutes.
Critical teaching point:
o Prompt relief with nitroglycerin supports the diagnosis of angina (coronary
vasodilation and reduced preload).
o Borrowing someone else’s medication is dangerous – potential for
severe hypotension, especially if patient is on PDE5 inhibitors (e.g.,
Week 7 I-Human
CASE
I-HUMAN PATIENTS CASE STUDY: ASSESSING THE
CARDIOVASCULAR SYSTEM
Case Title: Exertional Chest Pressure in a Patient with Multiple
Risk Factors
Patient: Eleanor Vance
Age: 68 years
Gender: Female
I-HUMAN PATIENTS CASE STUDY:
Race/Ethnicity: Non-Hispanic White
ASSESSING THE CARDIOVASCULAR SYSTEM
Setting: Outpatient Primary Care Clinic (follow-up visit for hypertension management)
Date of Encounter: March 15, 2026
1. Chief Complaint (Presenting Problem)
“I’ve been feeling a heavy, uncomfortable pressure right in the middle of my chest when I
walk up the hill to my mailbox. It goes away after I sit down and rest for a few minutes.
But yesterday, it lasted longer and felt a bit worse than before.”
, I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
Duration: Intermittent symptoms for 3 weeks, with a notable worsening episode 24
hours prior to presentation.
Student Note: The patient’s description of “pressure” rather than sharp or stabbing
pain, the relationship to exertion, and the relief with rest are classic for angina pectoris.
The recent worsening (increased duration and intensity) raises concern for possible
progression to unstable angina or an acute coronary syndrome (ACS) , even if the
pattern remains largely exertional.
2. History of Presenting Illness (HPI) – Expanded with
Clinical Pearls
The student must systematically characterize the symptom using the OLDCARTS
mnemonic, but also explore risk factors, associated symptoms, and medication
history (including potential inappropriate use of others’ medications).
Onset
• First noticed approximately 3 weeks ago while gardening (pulling weeds,
bending, light exertion). Initially dismissed as “muscle strain” or “indigestion.”
• Most concerning episode occurred yesterday at 7:00 PM while cooking dinner
(standing, stirring, minimal exertion compared to gardening). This episode was
different: longer duration and accompanied by mild nausea.
Location
• Substernal, central chest – patient points to the middle of the sternum with a
closed fist (positive Levine’s sign).
Clinical pearl: Levine’s sign (clenched fist over sternum) is highly suggestive of
ischemic cardiac pain.
• No radiation to jaw, neck, left shoulder/arm, or back.
Note: Absence of radiation does NOT rule out angina; many patients, especially
women and diabetics, have atypical or no radiation.
, I-HUMAN PATIENTS CASE STUDY: ASSESSING THE CARDIOVASCULAR SYSTEM
Duration
• Typical episodes: 2–3 minutes after stopping exertion.
• Yesterday’s episode: 10 minutes (even after stopping activity and sitting down).
This is a red flag – prolonged duration suggests possible unstable angina or non-
ST-elevation myocardial infarction (NSTEMI).
Character
• “Heavy,” “tight,” “like a vise grip” or “someone sitting on my chest.”
• Denies sharp, stabbing, burning, or pleuritic quality.
Pleuritic pain (worse with deep breath) would suggest pericarditis, pneumothorax,
or pulmonary embolism – not typical for stable angina.
Aggravating Factors
• Exertion: Walking >100 yards (especially uphill), climbing one flight of stairs,
heavy housework (mopping, carrying groceries).
• Emotional stress: Arguments with her husband (“when we fight, I feel it in my
chest”).
• Cold weather: Walking outside in winter air triggers symptoms more quickly.
Mechanism: Cold exposure increases systemic vascular resistance and myocardial
oxygen demand.
• Large meals: Eating a heavy dinner (especially high-fat) may provoke symptoms
30–60 minutes later – postprandial angina due to splanchnic shunting of blood.
Relieving Factors
• Rest: Sitting or lying down for 2–3 minutes consistently relieves typical episodes.
• Nitroglycerin: She took one of her husband’s nitroglycerin tablets (0.4 mg
sublingual) during yesterday’s episode. Pain improved within 3 minutes.
Critical teaching point:
o Prompt relief with nitroglycerin supports the diagnosis of angina (coronary
vasodilation and reduced preload).
o Borrowing someone else’s medication is dangerous – potential for
severe hypotension, especially if patient is on PDE5 inhibitors (e.g.,
