I-HUMAN CASE STUDY FOR A 58 YEARS OLD MAN WITH — WEEK 10 FOR WALDEN UNIVERSITY LOCATION :OUTPATIENT CLINIC WITH Chest pressure and shortness of breath for 2 hours X-RAY, ECG, AND LABORATORY CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE

I-HUMAN CASE STUDY FOR A 58 YEARS OLD MAN WITH — WEEK
10 FOR WALDEN UNIVERSITY LOCATION :OUTPATIENT CLINIC
WITH Chest pressure and shortness of breath for 2 hours X-RAY,
ECG, AND LABORATORY CAPABILITIES FULL CASE STUDY WITH A
SOAP NOTE




Simulated Clinical Case Presentation

Patient Identification

Name: John Miller
Age: 58 years
Sex: Male
Location: Emergency Department
Chief Complaint: “Chest pressure and shortness of breath for 2 hours”

,History of Present Illness (HPI)

John Miller is a 58-year-old male who presents to the emergency
department with 2 hours of substernal chest pressure accompanied by
shortness of breath. The chest pressure is described as heavy and
squeezing, rated 8/10, and radiates to the left arm and jaw. Symptoms
began while he was walking up stairs at home and did not resolve with
rest. He reports associated diaphoresis, nausea, and lightheadedness.
He denies recent trauma, fever, cough, or palpitations. No prior similar
episodes of this severity.



Past Medical History

• Hypertension (10 years)
• Type 2 Diabetes Mellitus
• Hyperlipidemia

Surgical History

• None reported



Medications

• Lisinopril 20 mg PO daily
• Metformin 1000 mg PO BID
• Atorvastatin 40 mg PO nightly

, Allergies

• No known drug allergies (NKDA)



Family History

• Father: Myocardial infarction at age 60
• Mother: Hypertension



Social History

• Former smoker (30 pack-years, quit 5 years ago)
• Occasional alcohol use
• Denies illicit drug use
• Sedentary lifestyle



Review of Systems (Pertinent Positives)

• Cardiovascular: Chest pressure, diaphoresis
• Respiratory: Shortness of breath
• GI: Nausea
• Neurologic: Lightheadedness



Physical Examination

Vital Signs