CLINICAL CASE REPORT
i-Human Case Week #7 | Advanced Health Assessment & Pathophysiology CONFIDENTIAL EHR
1. EXECUTIVE CASE SUMMARY & ENCOUNTER METADATA
PATIENT NAME AGE / GENDER ANTHROPOMETRICS
Karen Barnes 49 y/o Female 5′ 6″ (168 cm) | 158 lb (71.8 kg)
CALCULATED BMI ENCOUNTER SETTING CHIEF COMPLAINT (CC)
25.5 kg/m² (Overweight) Outpatient Cardiology Clinic "Intermittent squeezing chest
pain"
⚠ CLINICAL ALERT: ANGINAL WARNING SYMPTOMS
The patient presents with classic exertional mid-sternal chest discomfort radiating to the left arm, exacerbated by cold weather
exposure and physical effort, and relieved within minutes by rest. This clinical pattern is highly suspicious for stable angina pectoris
secondary to obstructive coronary artery disease (CAD). Immediate risk stratification and diagnostic evaluation are required.
Encounter Context & Encounter Narrative
Ms. Karen Barnes is a 49-year-old female who presents to the outpatient clinic reporting a 2-week history of episodic,
squeezing substernal chest discomfort. The initial episode occurred during a cross-country ski run in cold temperatures.
Since then, she has experienced similar episodes 1 to 2 times per week, typically triggered by exertion such as brisk
walking in cold air or climbing stairs, lasting 3 to 5 minutes, and consistently resolving with rest. She reports associated
exertional dyspnea but denies resting chest pain, syncope, palpitations, diaphoresis, or orthopnea.
Patient: Karen Barnes | DOB: 04/12/1977 Page 1 of 17 i-Human Clinical Documentation
,CLINICAL CASE REPORT
i-Human Case Week #7 | Advanced Health Assessment & Pathophysiology CONFIDENTIAL EHR
Primary Educational & Clinical Learning Objectives
1. Advanced Symptom Differentiation: Systematically analyze chest pain presentations using the OLD-CARTS
framework to distinguish stable angina pectoris from acute coronary syndrome (ACS), gastroesophageal reflux disease
(GERD), musculoskeletal pain, and anxiety-related disorders.
2. Pathophysiologic Integration: Correlate myocardial oxygen demand-supply mismatch with coronary atherosclerosis,
myocardial ischemia, and endothelial dysfunction exaggerated by thermal vasospasm (cold air).
3. Diagnostic Workup & Risk Stratification: Develop a structured, cost-effective diagnostic strategy utilizing resting
ECG, high-sensitivity cardiac troponin, lipid panels, and non-invasive stress testing (e.g., Exercise Stress
Echocardiography).
4. Evidence-Based Management Plan: Construct an individualized therapeutic regimen incorporating lifestyle
modification, anti-anginal pharmacotherapy (beta-blockers, sublingual nitroglycerin), lipid-lowering therapies (high-
intensity statins), and antiplatelet agents (aspirin) aligned with ACC/AHA guidelines.
Patient: Karen Barnes | DOB: 04/12/1977 Page 2 of 17 i-Human Clinical Documentation
, COMPREHENSIVE PATIENT HISTORY LOG
Section 2.3: Structured Clinical Interview (Questions 1–6) HISTORY LOG (3/2)
The following log documents the structured interview conducted during the i-Human virtual clinical patient encounter.
Questions were selected to establish symptom onset, character, precipitating factors, cardiovascular risk factors, and
pertinent negatives.
# I-HUMAN INTERVIEW QUESTION PATIENT RESPONSE CLINICAL RATIONALE & INTERPRETATION
1 "What brings you to the clinic "I've been having this intermittent squeezing Establishes chief complaint. Quality
today?" feeling in my chest over the last two weeks." ("squeezing") is classic for myocardial
ischemia. Timelines (2 weeks) suggests
subacute onset.
2 "How bad is the pain on a scale of 1 "When it happens, it's about a 5 or 6 out of 10. Quantifies symptom severity. Moderate
to 10?" It's not unbearable, but it definitely makes me intensity pain that enforces activity
stop what I'm doing." cessation is typical for stable angina.
3 "Where exactly do you feel the pain, "It's right in the middle of my chest, behind my Substernal location with radiation to
and does it spread anywhere else?" breastbone. Sometimes it radiates into my left the left arm has a high positive
arm." likelihood ratio for coronary artery
ischemia.
4 "What were you doing when this "It first happened two weeks ago while I was Identifies cold air exposure and intense
chest pain first started?" cross-country skiing on a cold afternoon." aerobic physical exertion as dual
triggers for heightened myocardial
demand and vasospasm.
5 "How long does each episode of "Usually about 3 to 5 minutes. As soon as I sit Short duration (<15 minutes) and rapid
chest pain typically last?" down and rest, it gradually fades away." resolution with rest are key features
distinguishing stable angina from
unstable angina or acute MI.
6 "What makes the pain better or "Fast walking or walking up hills in the cold Classic exertion-dependency and rest-
worse?" makes it worse. Resting completely makes it relief pattern (Canadian Cardiovascular
go away within a few minutes." Society Class II angina definition).
💡 CLINICAL PEARL: DIAMOND-FORRESTER CRITERIA FOR ANGINA
Anginal chest pain is categorized into three components: (1) Substernal chest discomfort of characteristic quality and duration, (2)
Provoked by exertion or emotional stress, and (3) Relieved by rest and/or nitroglycerin. Typical Angina fulfills all 3 criteria; Atypical
Angina fulfills 2 criteria; Non-cardiac chest pain fulfills 1 or 0 criteria. Ms. Barnes presents with all 3 criteria (Typical Angina).
Patient: Karen Barnes | DOB: 04/12/1977 Page 3 of 17 i-Human Clinical Documentation
i-Human Case Week #7 | Advanced Health Assessment & Pathophysiology CONFIDENTIAL EHR
1. EXECUTIVE CASE SUMMARY & ENCOUNTER METADATA
PATIENT NAME AGE / GENDER ANTHROPOMETRICS
Karen Barnes 49 y/o Female 5′ 6″ (168 cm) | 158 lb (71.8 kg)
CALCULATED BMI ENCOUNTER SETTING CHIEF COMPLAINT (CC)
25.5 kg/m² (Overweight) Outpatient Cardiology Clinic "Intermittent squeezing chest
pain"
⚠ CLINICAL ALERT: ANGINAL WARNING SYMPTOMS
The patient presents with classic exertional mid-sternal chest discomfort radiating to the left arm, exacerbated by cold weather
exposure and physical effort, and relieved within minutes by rest. This clinical pattern is highly suspicious for stable angina pectoris
secondary to obstructive coronary artery disease (CAD). Immediate risk stratification and diagnostic evaluation are required.
Encounter Context & Encounter Narrative
Ms. Karen Barnes is a 49-year-old female who presents to the outpatient clinic reporting a 2-week history of episodic,
squeezing substernal chest discomfort. The initial episode occurred during a cross-country ski run in cold temperatures.
Since then, she has experienced similar episodes 1 to 2 times per week, typically triggered by exertion such as brisk
walking in cold air or climbing stairs, lasting 3 to 5 minutes, and consistently resolving with rest. She reports associated
exertional dyspnea but denies resting chest pain, syncope, palpitations, diaphoresis, or orthopnea.
Patient: Karen Barnes | DOB: 04/12/1977 Page 1 of 17 i-Human Clinical Documentation
,CLINICAL CASE REPORT
i-Human Case Week #7 | Advanced Health Assessment & Pathophysiology CONFIDENTIAL EHR
Primary Educational & Clinical Learning Objectives
1. Advanced Symptom Differentiation: Systematically analyze chest pain presentations using the OLD-CARTS
framework to distinguish stable angina pectoris from acute coronary syndrome (ACS), gastroesophageal reflux disease
(GERD), musculoskeletal pain, and anxiety-related disorders.
2. Pathophysiologic Integration: Correlate myocardial oxygen demand-supply mismatch with coronary atherosclerosis,
myocardial ischemia, and endothelial dysfunction exaggerated by thermal vasospasm (cold air).
3. Diagnostic Workup & Risk Stratification: Develop a structured, cost-effective diagnostic strategy utilizing resting
ECG, high-sensitivity cardiac troponin, lipid panels, and non-invasive stress testing (e.g., Exercise Stress
Echocardiography).
4. Evidence-Based Management Plan: Construct an individualized therapeutic regimen incorporating lifestyle
modification, anti-anginal pharmacotherapy (beta-blockers, sublingual nitroglycerin), lipid-lowering therapies (high-
intensity statins), and antiplatelet agents (aspirin) aligned with ACC/AHA guidelines.
Patient: Karen Barnes | DOB: 04/12/1977 Page 2 of 17 i-Human Clinical Documentation
, COMPREHENSIVE PATIENT HISTORY LOG
Section 2.3: Structured Clinical Interview (Questions 1–6) HISTORY LOG (3/2)
The following log documents the structured interview conducted during the i-Human virtual clinical patient encounter.
Questions were selected to establish symptom onset, character, precipitating factors, cardiovascular risk factors, and
pertinent negatives.
# I-HUMAN INTERVIEW QUESTION PATIENT RESPONSE CLINICAL RATIONALE & INTERPRETATION
1 "What brings you to the clinic "I've been having this intermittent squeezing Establishes chief complaint. Quality
today?" feeling in my chest over the last two weeks." ("squeezing") is classic for myocardial
ischemia. Timelines (2 weeks) suggests
subacute onset.
2 "How bad is the pain on a scale of 1 "When it happens, it's about a 5 or 6 out of 10. Quantifies symptom severity. Moderate
to 10?" It's not unbearable, but it definitely makes me intensity pain that enforces activity
stop what I'm doing." cessation is typical for stable angina.
3 "Where exactly do you feel the pain, "It's right in the middle of my chest, behind my Substernal location with radiation to
and does it spread anywhere else?" breastbone. Sometimes it radiates into my left the left arm has a high positive
arm." likelihood ratio for coronary artery
ischemia.
4 "What were you doing when this "It first happened two weeks ago while I was Identifies cold air exposure and intense
chest pain first started?" cross-country skiing on a cold afternoon." aerobic physical exertion as dual
triggers for heightened myocardial
demand and vasospasm.
5 "How long does each episode of "Usually about 3 to 5 minutes. As soon as I sit Short duration (<15 minutes) and rapid
chest pain typically last?" down and rest, it gradually fades away." resolution with rest are key features
distinguishing stable angina from
unstable angina or acute MI.
6 "What makes the pain better or "Fast walking or walking up hills in the cold Classic exertion-dependency and rest-
worse?" makes it worse. Resting completely makes it relief pattern (Canadian Cardiovascular
go away within a few minutes." Society Class II angina definition).
💡 CLINICAL PEARL: DIAMOND-FORRESTER CRITERIA FOR ANGINA
Anginal chest pain is categorized into three components: (1) Substernal chest discomfort of characteristic quality and duration, (2)
Provoked by exertion or emotional stress, and (3) Relieved by rest and/or nitroglycerin. Typical Angina fulfills all 3 criteria; Atypical
Angina fulfills 2 criteria; Non-cardiac chest pain fulfills 1 or 0 criteria. Ms. Barnes presents with all 3 criteria (Typical Angina).
Patient: Karen Barnes | DOB: 04/12/1977 Page 3 of 17 i-Human Clinical Documentation
