Comprehensive iHuman Case Study: Expert Clinical Evaluation of a
69-Year-Old Male Presenting With Chest Pain in an Outpatient
Clinic Setting | Week 4 | NURS 6531
In-depth Week 4 iHuman case analysis for NURS 6531 featuring a 69-year-old male with chest pain.
Includes comprehensive outpatient clinical assessment, differential diagnoses, expert evaluation,
diagnostic reasoning, and evidence-based management plan.
,Patient Profile
• Age: 69 years
• Gender: Male
• Setting: Outpatient Clinic
• Chief Complaint: Chest pain
S – Subjective
Chief Complaint (CC)
"I’ve been having chest pain for the past few days."
History of Present Illness (HPI)
The patient is a 69-year-old male who presents to the outpatient clinic with complaints of chest
pain that began approximately 3 days ago. He describes the pain as a pressure-like sensation
located in the mid-sternal region, rated 6/10 in intensity. The pain intermittently radiates to the left
shoulder and jaw. Symptoms are aggravated by physical exertion and relieved with rest. The patient
reports associated shortness of breath and mild diaphoresis during episodes. He denies nausea,
vomiting, syncope, fever, cough, or recent trauma. No prior similar episodes reported.
Past Medical History (PMH)
• Hypertension (diagnosed 15 years ago)
• Hyperlipidemia
• Type 2 Diabetes Mellitus
Surgical History
• Appendectomy (age 25)
Medications
• Lisinopril 20 mg PO daily
• Atorvastatin 40 mg PO nightly
• Metformin 500 mg PO BID
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Deceased at 72 from myocardial infarction
• Mother: History of hypertension
Social History
• Former smoker (30 pack-years, quit 10 years ago)
• Occasional alcohol use
, • Retired accountant
• Lives with spouse
Review of Systems (ROS)
• Cardiovascular: Positive for chest pain, dyspnea on exertion
• Respiratory: Denies cough or wheezing
• Gastrointestinal: Denies nausea or reflux
• Neurological: Denies dizziness or weakness
• General: Denies fever or weight loss
O – Objective
Vital Signs
• Blood Pressure: 152/88 mmHg
• Heart Rate: 92 bpm
• Respiratory Rate: 20 breaths/min
• Temperature: 98.4°F (36.9°C)
• Oxygen Saturation: 96% on room air
Physical Examination
• General: Alert, oriented, mildly anxious
• Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, gallops, or
rubs
• Respiratory: Lungs clear to auscultation bilaterally
• Chest Wall: No tenderness to palpation
• Abdomen: Soft, non-tender, normoactive bowel sounds
• Extremities: No edema, pulses 2+ bilaterally
• Neurological: Alert and oriented x3, no focal deficits
Diagnostic Studies
• ECG: ST-segment depression noted in leads II, III, and aVF
• Troponin I: Pending
• Lipid Panel: Elevated LDL
• HbA1c: 7.8%
A – Assessment
Primary Diagnosis
• Stable Angina Pectoris (ICD-10: I20.9)
Differential Diagnoses
1. Acute Coronary Syndrome (ACS)
2. Gastroesophageal Reflux Disease (GERD)
, 3. Costochondritis
4. Pulmonary Embolism
Clinical presentation, risk factors, and ECG changes are most consistent with stable angina.
P – Plan
Diagnostics
• Serial troponin levels
• Stress test referral
• Echocardiogram
Medications
• Initiate Aspirin 81 mg PO daily
• Start Metoprolol 25 mg PO BID
• Prescribe Nitroglycerin 0.4 mg SL PRN chest pain
• Continue current antihypertensive, statin, and diabetic medications
Lifestyle Modifications
• Low-sodium, heart-healthy diet
• Regular moderate exercise as tolerated
• Smoking cessation reinforcement
• Weight management counseling
Patient Education
• Educate on recognizing signs of myocardial infarction
• Instruct to seek emergency care if chest pain persists or worsens
• Medication adherence emphasized
Follow-Up
• Cardiology referral within 1 week
• Return to clinic in 2 weeks for reassessment
69-Year-Old Male Presenting With Chest Pain in an Outpatient
Clinic Setting | Week 4 | NURS 6531
In-depth Week 4 iHuman case analysis for NURS 6531 featuring a 69-year-old male with chest pain.
Includes comprehensive outpatient clinical assessment, differential diagnoses, expert evaluation,
diagnostic reasoning, and evidence-based management plan.
,Patient Profile
• Age: 69 years
• Gender: Male
• Setting: Outpatient Clinic
• Chief Complaint: Chest pain
S – Subjective
Chief Complaint (CC)
"I’ve been having chest pain for the past few days."
History of Present Illness (HPI)
The patient is a 69-year-old male who presents to the outpatient clinic with complaints of chest
pain that began approximately 3 days ago. He describes the pain as a pressure-like sensation
located in the mid-sternal region, rated 6/10 in intensity. The pain intermittently radiates to the left
shoulder and jaw. Symptoms are aggravated by physical exertion and relieved with rest. The patient
reports associated shortness of breath and mild diaphoresis during episodes. He denies nausea,
vomiting, syncope, fever, cough, or recent trauma. No prior similar episodes reported.
Past Medical History (PMH)
• Hypertension (diagnosed 15 years ago)
• Hyperlipidemia
• Type 2 Diabetes Mellitus
Surgical History
• Appendectomy (age 25)
Medications
• Lisinopril 20 mg PO daily
• Atorvastatin 40 mg PO nightly
• Metformin 500 mg PO BID
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Deceased at 72 from myocardial infarction
• Mother: History of hypertension
Social History
• Former smoker (30 pack-years, quit 10 years ago)
• Occasional alcohol use
, • Retired accountant
• Lives with spouse
Review of Systems (ROS)
• Cardiovascular: Positive for chest pain, dyspnea on exertion
• Respiratory: Denies cough or wheezing
• Gastrointestinal: Denies nausea or reflux
• Neurological: Denies dizziness or weakness
• General: Denies fever or weight loss
O – Objective
Vital Signs
• Blood Pressure: 152/88 mmHg
• Heart Rate: 92 bpm
• Respiratory Rate: 20 breaths/min
• Temperature: 98.4°F (36.9°C)
• Oxygen Saturation: 96% on room air
Physical Examination
• General: Alert, oriented, mildly anxious
• Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, gallops, or
rubs
• Respiratory: Lungs clear to auscultation bilaterally
• Chest Wall: No tenderness to palpation
• Abdomen: Soft, non-tender, normoactive bowel sounds
• Extremities: No edema, pulses 2+ bilaterally
• Neurological: Alert and oriented x3, no focal deficits
Diagnostic Studies
• ECG: ST-segment depression noted in leads II, III, and aVF
• Troponin I: Pending
• Lipid Panel: Elevated LDL
• HbA1c: 7.8%
A – Assessment
Primary Diagnosis
• Stable Angina Pectoris (ICD-10: I20.9)
Differential Diagnoses
1. Acute Coronary Syndrome (ACS)
2. Gastroesophageal Reflux Disease (GERD)
, 3. Costochondritis
4. Pulmonary Embolism
Clinical presentation, risk factors, and ECG changes are most consistent with stable angina.
P – Plan
Diagnostics
• Serial troponin levels
• Stress test referral
• Echocardiogram
Medications
• Initiate Aspirin 81 mg PO daily
• Start Metoprolol 25 mg PO BID
• Prescribe Nitroglycerin 0.4 mg SL PRN chest pain
• Continue current antihypertensive, statin, and diabetic medications
Lifestyle Modifications
• Low-sodium, heart-healthy diet
• Regular moderate exercise as tolerated
• Smoking cessation reinforcement
• Weight management counseling
Patient Education
• Educate on recognizing signs of myocardial infarction
• Instruct to seek emergency care if chest pain persists or worsens
• Medication adherence emphasized
Follow-Up
• Cardiology referral within 1 week
• Return to clinic in 2 weeks for reassessment
