Comprehensive Advanced Health
Assessment
Clinical Case Report
iHuman Patient Simulation
Hua Zhang
Acute Substernal Chest Pain – NSTEMI
E
US
HO
OL
HO
SC
Prepared By: SchoolHouse
MRN: 984-221-04
Academic Draft - For Educational & Simulation Use Only
Advanced Practice Nursing / Clinical Medical Candidate
©SchoolHouse Academic Publishing
,Executive Case Summary
Mrs. Hua Zhang is a 69-year-old postmenopausal female with a significant medical his-
tory of poorly controlled Type 2 Diabetes Mellitus, Essential Hypertension, and Primary
Hyperlipidemia who presents to the Urgent Care clinic via self-transport complaining of
acute substernal chest discomfort that began 3 hours prior to arrival during mild external
activity (climbing a flight of stairs). The patient describes the pain as a heavy, squeezing
pressure rated at 7/10 in severity, radiating to her left inner arm and lower jaw. The pain
was accompanied by moderate diaphoresis, acute dyspnea, and mild nausea. Initial phys-
ical examination revealed borderline hemodynamic stability (BP 154/92 mmHg, HR 98
bpm, SpO2 95% on room air). Electrocardiography (12-lead ECG) demonstrated 1.5mm
horizontal ST-segment depressions and symmetrical T-wave inversions in leads V4-V6.
High-sensitivity cardiac troponin I (hs-cTnI) returned significantly elevated at 485 ng/L
(normal < 16 ng/L), establishing a primary working diagnosis of Acute Non-ST-Segment
Elevation Myocardial Infarction (NSTEMI).
E
Emergency protocol was initiated including immediate dual antiplatelet therapy (DAPT),
US
systemic anticoagulation, intravenous nitroglycerin, and urgent transfer to the tertiary
HO
OL
cardiac catheterization laboratory.
HO
SC
Encounter Metadata & Baseline Metrics
Setting & Provider Metadata Initial Clinical Triage Markers
Encounter Setting: Outpatient Urgent Triage Acuity: Level 2 (Emergent - ESI
Care Center / ED Transfer Level 2)
Attending Provider: Clinical Educator TIMI Risk Score: 5 points (High Risk -
/ Lead NP 26.3% 14-day MACE)
Chief Complaint: "Squeezing chest pain HEART Score: 7 points (High
for 3 hours" Risk - Recommend Inpatient Ad-
mission/Cath)
Code Status: Full Code GRACE Score: 138 (Intermediate-High
In-Hospital Mortality Risk)
Allergies: NKDA
Primary Learning & Competency Objectives
1. Advanced Assessment: Differentiate atypical and typical acute coronary syn-
drome (ACS) presentations in elderly diabetic females.
1
, 2. Diagnostic Integration: Rapidly interpret 12-lead ECG findings and serial car-
diac biomarker kinetics to differentiate NSTEMI from STEMI and Unstable Angina.
3. Risk Stratification: Apply validated clinical scoring tools (HEART, TIMI, GRACE)
to dictate immediate therapeutic escalation versus conservative management.
4. Pharmacotherapeutic Management: Formulate evidence-based antiplatelet,
anticoagulant, anti-ischemic, and lipid-lowering regimens aligned with AHA/ACC
guidelines.
5. Interprofessional Communication: Execute structured clinical handoffs (SBAR)
and produce exhaustive EHR SOAP documentation and patient discharge educa-
tion sheets.
Critical Clinical Alert
Diabetic patients, especially elderly females, frequently present with atypical symptoms
of myocardial ischemia. Absence of crushing substernal chest pain does NOT rule out
acute coronary syndromes. Dyspnea, unexplained diaphoresis, and sudden fatigue should
prompt immediate 12-lead ECG acquisition.
E
US
HO
OL
HO
SC
Prepared by SchoolHouse
Confidential - Clinical Education Simulation Page 2
Assessment
Clinical Case Report
iHuman Patient Simulation
Hua Zhang
Acute Substernal Chest Pain – NSTEMI
E
US
HO
OL
HO
SC
Prepared By: SchoolHouse
MRN: 984-221-04
Academic Draft - For Educational & Simulation Use Only
Advanced Practice Nursing / Clinical Medical Candidate
©SchoolHouse Academic Publishing
,Executive Case Summary
Mrs. Hua Zhang is a 69-year-old postmenopausal female with a significant medical his-
tory of poorly controlled Type 2 Diabetes Mellitus, Essential Hypertension, and Primary
Hyperlipidemia who presents to the Urgent Care clinic via self-transport complaining of
acute substernal chest discomfort that began 3 hours prior to arrival during mild external
activity (climbing a flight of stairs). The patient describes the pain as a heavy, squeezing
pressure rated at 7/10 in severity, radiating to her left inner arm and lower jaw. The pain
was accompanied by moderate diaphoresis, acute dyspnea, and mild nausea. Initial phys-
ical examination revealed borderline hemodynamic stability (BP 154/92 mmHg, HR 98
bpm, SpO2 95% on room air). Electrocardiography (12-lead ECG) demonstrated 1.5mm
horizontal ST-segment depressions and symmetrical T-wave inversions in leads V4-V6.
High-sensitivity cardiac troponin I (hs-cTnI) returned significantly elevated at 485 ng/L
(normal < 16 ng/L), establishing a primary working diagnosis of Acute Non-ST-Segment
Elevation Myocardial Infarction (NSTEMI).
E
Emergency protocol was initiated including immediate dual antiplatelet therapy (DAPT),
US
systemic anticoagulation, intravenous nitroglycerin, and urgent transfer to the tertiary
HO
OL
cardiac catheterization laboratory.
HO
SC
Encounter Metadata & Baseline Metrics
Setting & Provider Metadata Initial Clinical Triage Markers
Encounter Setting: Outpatient Urgent Triage Acuity: Level 2 (Emergent - ESI
Care Center / ED Transfer Level 2)
Attending Provider: Clinical Educator TIMI Risk Score: 5 points (High Risk -
/ Lead NP 26.3% 14-day MACE)
Chief Complaint: "Squeezing chest pain HEART Score: 7 points (High
for 3 hours" Risk - Recommend Inpatient Ad-
mission/Cath)
Code Status: Full Code GRACE Score: 138 (Intermediate-High
In-Hospital Mortality Risk)
Allergies: NKDA
Primary Learning & Competency Objectives
1. Advanced Assessment: Differentiate atypical and typical acute coronary syn-
drome (ACS) presentations in elderly diabetic females.
1
, 2. Diagnostic Integration: Rapidly interpret 12-lead ECG findings and serial car-
diac biomarker kinetics to differentiate NSTEMI from STEMI and Unstable Angina.
3. Risk Stratification: Apply validated clinical scoring tools (HEART, TIMI, GRACE)
to dictate immediate therapeutic escalation versus conservative management.
4. Pharmacotherapeutic Management: Formulate evidence-based antiplatelet,
anticoagulant, anti-ischemic, and lipid-lowering regimens aligned with AHA/ACC
guidelines.
5. Interprofessional Communication: Execute structured clinical handoffs (SBAR)
and produce exhaustive EHR SOAP documentation and patient discharge educa-
tion sheets.
Critical Clinical Alert
Diabetic patients, especially elderly females, frequently present with atypical symptoms
of myocardial ischemia. Absence of crushing substernal chest pain does NOT rule out
acute coronary syndromes. Dyspnea, unexplained diaphoresis, and sudden fatigue should
prompt immediate 12-lead ECG acquisition.
E
US
HO
OL
HO
SC
Prepared by SchoolHouse
Confidential - Clinical Education Simulation Page 2
