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iHuman Case Study: Week #7Reason for Encounter: Chest Pain with Rationales
Patient Demographics: 26-year-old male
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
Case StudyPatient Information
Name: Michael James Carter (fictional for illustrative purposes)
Age: 26 years
Gender: Male
Chief Complaint: Chest pain
Setting: Outpatient clinic
History of Present Illness (HPI)Michael James Carter, a 26-year-old male, presents to the
outpatient clinic complaining of chest pain for the past three days. He describes the pain as
a sharp, stabbing sensation localized to the left anterior chest, rated 6/10 at its worst. The
pain is exacerbated by deep inspiration, coughing, and lying flat, but it improves when
sitting upright or leaning forward. He reports the pain is intermittent, lasting minutes to
hours, and is not related to exertion. Associated symptoms include:
A dry, non-productive cough that started two days ago.
Subjective fever and chills over the past two days, though he has not measured his
temperature.
Mild shortness of breath, particularly with exertion or when the chest pain is severe.
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Fatigue, which he attributes to poor sleep due to discomfort.
He denies:
Radiation of pain to the arm, jaw, or back.
Palpitations, syncope, or dizziness.
Recent trauma, injury, or heavy lifting.
Hemoptysis, weight loss, or night sweats.
Recent travel, prolonged immobility, or known exposure to sick contacts.
The patient reports feeling “under the weather” for about a week prior to the onset of chest
pain, with mild upper respiratory symptoms (e.g., nasal congestion) that resolved
spontaneously. He denies any history of similar symptoms in the past.
Past Medical History (PMH)
Seasonal Allergies: Managed with over-the-counter cetirizine as needed.
No history of asthma, hypertension, diabetes, heart disease, or pulmonary conditions.
No prior surgeries or hospitalizations.
Allergies: No known drug or food allergies; allergic to pollen (seasonal).
Medications
Cetirizine 10 mg as needed for seasonal allergies (last taken one week ago).
No other prescription or over-the-counter medications.
iHuman Case Study: Week #7Reason for Encounter: Chest Pain with Rationales
Patient Demographics: 26-year-old male
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
Case StudyPatient Information
Name: Michael James Carter (fictional for illustrative purposes)
Age: 26 years
Gender: Male
Chief Complaint: Chest pain
Setting: Outpatient clinic
History of Present Illness (HPI)Michael James Carter, a 26-year-old male, presents to the
outpatient clinic complaining of chest pain for the past three days. He describes the pain as
a sharp, stabbing sensation localized to the left anterior chest, rated 6/10 at its worst. The
pain is exacerbated by deep inspiration, coughing, and lying flat, but it improves when
sitting upright or leaning forward. He reports the pain is intermittent, lasting minutes to
hours, and is not related to exertion. Associated symptoms include:
A dry, non-productive cough that started two days ago.
Subjective fever and chills over the past two days, though he has not measured his
temperature.
Mild shortness of breath, particularly with exertion or when the chest pain is severe.
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Fatigue, which he attributes to poor sleep due to discomfort.
He denies:
Radiation of pain to the arm, jaw, or back.
Palpitations, syncope, or dizziness.
Recent trauma, injury, or heavy lifting.
Hemoptysis, weight loss, or night sweats.
Recent travel, prolonged immobility, or known exposure to sick contacts.
The patient reports feeling “under the weather” for about a week prior to the onset of chest
pain, with mild upper respiratory symptoms (e.g., nasal congestion) that resolved
spontaneously. He denies any history of similar symptoms in the past.
Past Medical History (PMH)
Seasonal Allergies: Managed with over-the-counter cetirizine as needed.
No history of asthma, hypertension, diabetes, heart disease, or pulmonary conditions.
No prior surgeries or hospitalizations.
Allergies: No known drug or food allergies; allergic to pollen (seasonal).
Medications
Cetirizine 10 mg as needed for seasonal allergies (last taken one week ago).
No other prescription or over-the-counter medications.
