ENCOUNTER: CHEST PAIN LOCATION: OUTPATIENT
CLINIC WITH RADIOLOGY, ECG, AND LABORATORY
CAPABILITIES LATEST 2025/2026
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,Name: [Not specified] i i
Age: 69 i
Sex: Female i
Reason for Visit: Chest pain i i i i
Setting: Outpatient clinic (with ECG, radiology, and labs)
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1. Chief Complaint (CC): i i
"I’ve been having chest pain off and on for the past few days."
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2. History of Present Illness (HPI): i i i i
The patient reports chest pain that started 3 days ago. It is described as a
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pressure-like sensation located in the mid-sternum, occasionally i i i i i i
radiating to the left arm. The pain occurs mostly with physical activity, suc
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h as walking up stairs, and resolves with rest after a few minutes.
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Onset: 3 days ago i i i
Location: Center of chest i i i
Duration: Lasts about 5–10 minutes per episode i i i i i i
Character: Pressure-like, tightness i i
Radiation: Left arm i i
Associated symptoms: Mild shortness of breath, fatigue i i i i i i
Aggravating factors: Physical exertion i i i
Relieving factors: Rest i i
Severity: 6/10 during episodes i i i
Frequency: Occurs 1–2 times daily i i i i
, 3. Past Medical History (PMH):
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Hypertension (diagnosed 10 years ago) i i i i
Type 2 Diabetes Mellitus (controlled with metformin)
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Hyperlipidemia
Osteoarthritis
No known coronary artery disease (CAD) diagnosis but reports pa
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st episodes of “heartburn” and fatigue with activity
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4. Surgical History:
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Cholecystectomy (20 years ago) i i i
Cataract surgery (last year)
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5. Medications:
Metformin 500 mg BID i i i
Lisinopril 10 mg daily i i i
Atorvastatin 20 mg at night i i i i
Acetaminophen PRN i
Occasional antacid use i i
6. Allergies:
No known drug allergies
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