,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 chief complaint of chest pain for the past 3
days. He describes the pain as a heavy, burning sensation in the center
of his chest, rating it 5–7/10 in intensity. The episodes last 10–15
minutes, occur 3–4 times daily, and are triggered by physical exertion
(e.g., walking uphill, carrying groceries) or emotional stress (e.g.,
arguing with family). The pain occasionally radiates to his left shoulder
and neck, accompanied by mild shortness of breath and diaphoresis,
but no nausea, vomiting, or syncope. Rest or sitting down typically
relieves the pain within 5–10 minutes. He has not tried medications like
,nitroglycerin or antacids. The frequency and intensity of episodes have
increased slightly over the 3 days, prompting concern about a possible
heart problem, especially given his history of smoking and family
history of heart disease. The patient denies recent trauma, injury, or
changes in exercise tolerance prior to symptom onset. He reports no
fever, cough, weight loss, or gastrointestinal symptoms (e.g.,
heartburn, epigastric pain) that might suggest a non-cardiac cause. He
has experienced occasional indigestion in the past but denies current
symptoms of acid reflux or association with meals. His last physical
exam was 18 months ago, with no reported cardiac issues, though his
blood pressure and cholesterol were noted to be “high.” He is
concerned about his ability to remain active and fears a heart attack,
given his father’s history of myocardial infarction (MI) at age 65.
Medical History
Past Medical History:
Hypertension: Diagnosed at age 55 (14 years ago), managed
with hydrochlorothiazide 25 mg daily. Last blood pressure
check 6 months ago was 145/90 mmHg, indicating
suboptimal control (target <130/80 mmHg per 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%, indicating fair control (target <7.0%).
No history of coronary artery disease, myocardial infarction,
heart failure, arrhythmias, or stroke.
No history of respiratory disorders (e.g., COPD, asthma),
gastrointestinal conditions (e.g., GERD, peptic ulcer), or
musculoskeletal issues.
Surgical History:
Cholecystectomy at age 50 for gallstones, uncomplicated
recovery.
No other surgeries or hospitalizations.
Allergies: No known drug, food, or environmental allergies.
Medications:
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 chief complaint of chest pain for the past 3
days. He describes the pain as a heavy, burning sensation in the center
of his chest, rating it 5–7/10 in intensity. The episodes last 10–15
minutes, occur 3–4 times daily, and are triggered by physical exertion
(e.g., walking uphill, carrying groceries) or emotional stress (e.g.,
arguing with family). The pain occasionally radiates to his left shoulder
and neck, accompanied by mild shortness of breath and diaphoresis,
but no nausea, vomiting, or syncope. Rest or sitting down typically
relieves the pain within 5–10 minutes. He has not tried medications like
,nitroglycerin or antacids. The frequency and intensity of episodes have
increased slightly over the 3 days, prompting concern about a possible
heart problem, especially given his history of smoking and family
history of heart disease. The patient denies recent trauma, injury, or
changes in exercise tolerance prior to symptom onset. He reports no
fever, cough, weight loss, or gastrointestinal symptoms (e.g.,
heartburn, epigastric pain) that might suggest a non-cardiac cause. He
has experienced occasional indigestion in the past but denies current
symptoms of acid reflux or association with meals. His last physical
exam was 18 months ago, with no reported cardiac issues, though his
blood pressure and cholesterol were noted to be “high.” He is
concerned about his ability to remain active and fears a heart attack,
given his father’s history of myocardial infarction (MI) at age 65.
Medical History
Past Medical History:
Hypertension: Diagnosed at age 55 (14 years ago), managed
with hydrochlorothiazide 25 mg daily. Last blood pressure
check 6 months ago was 145/90 mmHg, indicating
suboptimal control (target <130/80 mmHg per 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%, indicating fair control (target <7.0%).
No history of coronary artery disease, myocardial infarction,
heart failure, arrhythmias, or stroke.
No history of respiratory disorders (e.g., COPD, asthma),
gastrointestinal conditions (e.g., GERD, peptic ulcer), or
musculoskeletal issues.
Surgical History:
Cholecystectomy at age 50 for gallstones, uncomplicated
recovery.
No other surgeries or hospitalizations.
Allergies: No known drug, food, or environmental allergies.
Medications:
