,Patient Information
Name: Mei Yang
Age: 69 years old
Gender: Male
Height: 5’6” (168 cm, based on average for Asian-American males)
Weight: 165 lbs (75 kg, BMI 26.6 kg/m², overweight)
Reason for Encounter: Chest pain for 2 hours
Setting: Urgent care clinic, potential ED transfer
Class: 6512, Week #4, Chamberlain University
History of Present Illness (HPI)
Mei Yang, a 69-year-old Asian-American male, presents to the urgent
care clinic with chest pain for 2 hours, described as a heavy, squeezing
sensation in the substernal region, radiating to his left arm and jaw,
rated 7/10 in severity. The pain began abruptly at rest while watching
television, is persistent, and is accompanied by nausea, diaphoresis,
mild shortness of breath, and a sense of impending doom. He denies
relief with rest or a single dose of over-the-counter antacids (tried 30
minutes ago). Mei reports a 3-month history of intermittent exertional
,chest discomfort (Canadian Cardiovascular Society [CCS] Class II, 5–10
minutes, relieved by rest), which he attributed to “indigestion” and did
not seek evaluation for. He denies syncope, palpitations, fever, cough,
hemoptysis, leg swelling, or recent trauma. Mei is alarmed, fearing a
heart attack, given his father’s myocardial infarction (MI) at age 65.His
medical history includes hypertension (diagnosed 15 years ago,
controlled), type 2 diabetes mellitus (T2DM) (diagnosed 10 years ago,
HbA1c 7.5%), hyperlipidemia (controlled), and osteoarthritis (knees,
mild). He denies prior MI, heart failure, or diagnosed coronary artery
disease (CAD). Mei is a former smoker (20 pack-years, quit 10 years
ago), consumes 1–2 beers/week, and follows a traditional Asian diet
(rice, vegetables, fish, occasional fried foods, high sodium). He exercises
minimally (20 min walking, 2–3 times/week) due to knee pain. As a
retired accountant, he lives with his wife and reports moderate stress
managing family finances and supporting two adult children.
Onset: Acute, 2 hours ago at rest; prior exertional symptoms for 3
months.
Location: Substernal, radiating to left arm and jaw.
Duration: Continuous for 2 hours (acute); prior episodes 5–10
minutes.
, Characteristics: Heavy, squeezing, 7/10, with nausea, diaphoresis,
shortness of breath, impending doom.
Aggravating Factors: None for current episode (at rest); prior
episodes triggered by exertion (e.g., climbing stairs).
Relieving Factors: None for current episode (antacids ineffective);
prior episodes relieved by rest.
Associated Symptoms: Nausea, diaphoresis, mild shortness of
breath, impending doom; no syncope, palpitations, fever, or
cough.
Severity: Severe (7/10), prompting urgent care visit.
Relevant History:
Medical:
Hypertension: Controlled with losartan, diagnosed 15 years
ago.
Type 2 Diabetes Mellitus: HbA1c ~7.5%, managed with
metformin, diagnosed 10 years ago.
Hyperlipidemia: Controlled with atorvastatin, diagnosed 12
years ago.
Name: Mei Yang
Age: 69 years old
Gender: Male
Height: 5’6” (168 cm, based on average for Asian-American males)
Weight: 165 lbs (75 kg, BMI 26.6 kg/m², overweight)
Reason for Encounter: Chest pain for 2 hours
Setting: Urgent care clinic, potential ED transfer
Class: 6512, Week #4, Chamberlain University
History of Present Illness (HPI)
Mei Yang, a 69-year-old Asian-American male, presents to the urgent
care clinic with chest pain for 2 hours, described as a heavy, squeezing
sensation in the substernal region, radiating to his left arm and jaw,
rated 7/10 in severity. The pain began abruptly at rest while watching
television, is persistent, and is accompanied by nausea, diaphoresis,
mild shortness of breath, and a sense of impending doom. He denies
relief with rest or a single dose of over-the-counter antacids (tried 30
minutes ago). Mei reports a 3-month history of intermittent exertional
,chest discomfort (Canadian Cardiovascular Society [CCS] Class II, 5–10
minutes, relieved by rest), which he attributed to “indigestion” and did
not seek evaluation for. He denies syncope, palpitations, fever, cough,
hemoptysis, leg swelling, or recent trauma. Mei is alarmed, fearing a
heart attack, given his father’s myocardial infarction (MI) at age 65.His
medical history includes hypertension (diagnosed 15 years ago,
controlled), type 2 diabetes mellitus (T2DM) (diagnosed 10 years ago,
HbA1c 7.5%), hyperlipidemia (controlled), and osteoarthritis (knees,
mild). He denies prior MI, heart failure, or diagnosed coronary artery
disease (CAD). Mei is a former smoker (20 pack-years, quit 10 years
ago), consumes 1–2 beers/week, and follows a traditional Asian diet
(rice, vegetables, fish, occasional fried foods, high sodium). He exercises
minimally (20 min walking, 2–3 times/week) due to knee pain. As a
retired accountant, he lives with his wife and reports moderate stress
managing family finances and supporting two adult children.
Onset: Acute, 2 hours ago at rest; prior exertional symptoms for 3
months.
Location: Substernal, radiating to left arm and jaw.
Duration: Continuous for 2 hours (acute); prior episodes 5–10
minutes.
, Characteristics: Heavy, squeezing, 7/10, with nausea, diaphoresis,
shortness of breath, impending doom.
Aggravating Factors: None for current episode (at rest); prior
episodes triggered by exertion (e.g., climbing stairs).
Relieving Factors: None for current episode (antacids ineffective);
prior episodes relieved by rest.
Associated Symptoms: Nausea, diaphoresis, mild shortness of
breath, impending doom; no syncope, palpitations, fever, or
cough.
Severity: Severe (7/10), prompting urgent care visit.
Relevant History:
Medical:
Hypertension: Controlled with losartan, diagnosed 15 years
ago.
Type 2 Diabetes Mellitus: HbA1c ~7.5%, managed with
metformin, diagnosed 10 years ago.
Hyperlipidemia: Controlled with atorvastatin, diagnosed 12
years ago.
