,Patient Information
Name: James Thompson (per iHuman case documentation)
Age: 69 years
Gender: Male
Height: 5’8” (172.7 cm, ~30th percentile for age)
Weight: 200 lb (90.7 kg, BMI 30.4 kg/m², obese, range ≥30 kg/m²)
Reason for Encounter: Chest pain for 3 days, presenting to an
outpatient clinic with X-ray, ECG, and laboratory capabilities in
2024 for urgent evaluation.
History of Present Illness
James Thompson, a 69-year-old retired mechanic, presents to the
outpatient clinic with a 3-day history of intermittent chest pain. He
describes the pain as a heavy, burning sensation in the center of his
chest, rated 5–7/10 in intensity, lasting 10–15 minutes per episode. The
pain occurs 3–4 times daily, consistently triggered by physical exertion
(e.g., walking uphill, carrying groceries) or emotional stress (e.g., family
arguments) and occasionally radiates to his left shoulder and neck.
Associated symptoms include mild shortness of breath and diaphoresis,
without nausea, vomiting, palpitations, or syncope. Rest reliably
alleviates the pain within 5–10 minutes. He has not used nitroglycerin,
,antacids, or other medications for relief. The frequency and intensity of
episodes have slightly increased over the 3 days, prompting concern
about a potential heart attack, particularly given his father’s myocardial
infarction (MI) at age 65. Mr. Thompson denies recent trauma, injury,
or changes in exercise tolerance prior to symptom onset. He reports no
fever, chills, cough, weight loss, or gastrointestinal symptoms (e.g.,
heartburn, epigastric pain, regurgitation) suggestive of non-cardiac
causes. While he has a history of occasional indigestion, he denies
current acid reflux or meal-related symptoms. His last physical exam, 18
months ago, noted elevated blood pressure and cholesterol but no
cardiac symptoms. He is worried about his health and ability to
continue gardening and volunteering, expressing fear of a “heart
problem” impacting his retirement. Medical History
Past Medical History:
Hypertension: Diagnosed at age 55 (14 years ago), managed
with hydrochlorothiazide 25 mg daily. Last blood pressure (6
months ago) was 145/90 mmHg, indicating suboptimal
control (target <130/80 mmHg per 2017 AHA/ACC
guidelines).
Hyperlipidemia: Diagnosed at age 60, managed with
simvastatin 20 mg daily. Last lipid panel (6 months ago):
, Total cholesterol 210 mg/dL, LDL 130 mg/dL, HDL 40 mg/dL,
triglycerides 180 mg/dL (LDL above target <70 mg/dL for
high-risk patients).
Type 2 Diabetes Mellitus: Diagnosed at age 62, managed
with metformin 500 mg twice daily. Last HbA1c (6 months
ago) was 7.2% (target <7.0%, fair control).
No history of coronary artery disease (CAD), myocardial
infarction, heart failure, arrhythmias, stroke, or chronic
respiratory/gastrointestinal conditions.
Surgical History:
Cholecystectomy at age 50 for gallstones, uncomplicated
recovery.
No other surgeries or hospitalizations.
Allergies: No known allergies to medications, foods, or
environmental triggers.
Medications:
Hydrochlorothiazide 25 mg daily (hypertension).
Simvastatin 20 mg daily (hyperlipidemia).
Metformin 500 mg twice daily (type 2 diabetes).
Name: James Thompson (per iHuman case documentation)
Age: 69 years
Gender: Male
Height: 5’8” (172.7 cm, ~30th percentile for age)
Weight: 200 lb (90.7 kg, BMI 30.4 kg/m², obese, range ≥30 kg/m²)
Reason for Encounter: Chest pain for 3 days, presenting to an
outpatient clinic with X-ray, ECG, and laboratory capabilities in
2024 for urgent evaluation.
History of Present Illness
James Thompson, a 69-year-old retired mechanic, presents to the
outpatient clinic with a 3-day history of intermittent chest pain. He
describes the pain as a heavy, burning sensation in the center of his
chest, rated 5–7/10 in intensity, lasting 10–15 minutes per episode. The
pain occurs 3–4 times daily, consistently triggered by physical exertion
(e.g., walking uphill, carrying groceries) or emotional stress (e.g., family
arguments) and occasionally radiates to his left shoulder and neck.
Associated symptoms include mild shortness of breath and diaphoresis,
without nausea, vomiting, palpitations, or syncope. Rest reliably
alleviates the pain within 5–10 minutes. He has not used nitroglycerin,
,antacids, or other medications for relief. The frequency and intensity of
episodes have slightly increased over the 3 days, prompting concern
about a potential heart attack, particularly given his father’s myocardial
infarction (MI) at age 65. Mr. Thompson denies recent trauma, injury,
or changes in exercise tolerance prior to symptom onset. He reports no
fever, chills, cough, weight loss, or gastrointestinal symptoms (e.g.,
heartburn, epigastric pain, regurgitation) suggestive of non-cardiac
causes. While he has a history of occasional indigestion, he denies
current acid reflux or meal-related symptoms. His last physical exam, 18
months ago, noted elevated blood pressure and cholesterol but no
cardiac symptoms. He is worried about his health and ability to
continue gardening and volunteering, expressing fear of a “heart
problem” impacting his retirement. Medical History
Past Medical History:
Hypertension: Diagnosed at age 55 (14 years ago), managed
with hydrochlorothiazide 25 mg daily. Last blood pressure (6
months ago) was 145/90 mmHg, indicating suboptimal
control (target <130/80 mmHg per 2017 AHA/ACC
guidelines).
Hyperlipidemia: Diagnosed at age 60, managed with
simvastatin 20 mg daily. Last lipid panel (6 months ago):
, Total cholesterol 210 mg/dL, LDL 130 mg/dL, HDL 40 mg/dL,
triglycerides 180 mg/dL (LDL above target <70 mg/dL for
high-risk patients).
Type 2 Diabetes Mellitus: Diagnosed at age 62, managed
with metformin 500 mg twice daily. Last HbA1c (6 months
ago) was 7.2% (target <7.0%, fair control).
No history of coronary artery disease (CAD), myocardial
infarction, heart failure, arrhythmias, stroke, or chronic
respiratory/gastrointestinal conditions.
Surgical History:
Cholecystectomy at age 50 for gallstones, uncomplicated
recovery.
No other surgeries or hospitalizations.
Allergies: No known allergies to medications, foods, or
environmental triggers.
Medications:
Hydrochlorothiazide 25 mg daily (hypertension).
Simvastatin 20 mg daily (hyperlipidemia).
Metformin 500 mg twice daily (type 2 diabetes).
