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The assignment involves analyzing and documenting a comprehensive clinical case. The core tasks include presenting a chief complaint in the patient's own words, providing a detailed history of present illness (HPI), past medical history (PMH), past surgical history (PSH), family history, social habits, and relevant system information with normal and abnormal findings. Additionally, the objective section should include pertinent information such as drug allergies, physical findings, and medication list. The assessment should justify the primary diagnosis and rule out other potential disorders. The plan must discuss therapy options with pros and cons, include specific directives for treatment, and outline monitoring and follow-up strategies. Please also explain three differential diagnoses with supporting reasoning.

Sample Paper For Above instruction

Chief Complaint: “I have been experiencing persistent chest pain for the past three days,” the patient states in their own words. The patient describes the pain as a dull, pressure-like sensation localized to the center of the chest, radiating to the left arm, and associated with shortness of breath. The pain worsens with exertion and alleviates somewhat with rest.

History of Present Illness (HPI):

The patient, a 55-year-old male with a history of hypertension and hyperlipidemia, reports that the chest pain started three days ago, gradually increasing in intensity. He mentions episodes of dizziness and mild nausea accompanying the chest discomfort. The pain is relieved temporarily by resting and worsened by physical activity and emotional stress. No previous similar episodes were noted. No recent trauma or injury. The patient denies fever, cough, or palpitations.

Past Medical History (PMH):

• Hypertension diagnosed 10 years ago, managed with medication
• Hyperlipidemia diagnosed 5 years ago
• No known allergies

Past Surgical History (PSH):

• Appendectomy at age 20
• No other surgeries

Family History:

• Father had myocardial infarction at age 60
• Mother with hypertension and type 2 diabetes

Social Habits:

• Smokes half a pack of cigarettes daily for 30 years
• Occasional alcohol consumption
• Moderate physical activity, sedentary lifestyle otherwise

Physical Examination Findings:

Vital signs: BP 140/90 mmHg, HR 88 bpm, RR 16/min, Temperature 98.6°F.

Cardiovascular exam: Regular rhythm, no murmurs. Chest wall tender but no swelling.

Lungs: Clear to auscultation bilaterally.

Other systems: Unremarkable with no abnormal findings.

Assessment:

The primary diagnosis is stable angina pectoris, based on clinical presentation, history, and risk factors. Differential diagnoses include gastroesophageal reflux disease (GERD), musculoskeletal chest pain, and costochondritis, which need to be ruled out.

Justification for Primary Diagnosis:

The characteristic exertional chest pain, radiating to the arm, associated with exertion and relieved by rest, strongly suggests angina pectoris. The patient’s risk factors, such as hypertension, hyperlipidemia, age, and smoking history, further support this diagnosis.

Differential Diagnoses:

1. Gastroesophageal Reflux Disease (GERD): GERD can cause chest pain that mimics angina. The pain may be related to meals, lying down, or bending forward, and often does not radiate or worsen strictly with exertion. Absence of relief with nitroglycerin and the patient's risk factors make GERD less likely but still possible.
2. Musculoskeletal Chest Pain: This may be due to strain or injury to the chest wall muscles or costochondritis. Such pain tends to be reproducible on palpation, localized, and may worsen with movement or coughing. The patient’s description of a pressure sensation, however, weighs more toward cardiac etiology.
3. Costochondritis: Similar to musculoskeletal pain, it involves inflammation of the costochondral joints. The pain is often localized and reproducible. Lack of tenderness on palpation during physical exam makes this less probable.

Plan:

Therapy Options: Initial therapy includes nitrates (e.g., sublingual nitroglycerin) to relieve anginal pain, beta-blockers or calcium channel blockers to reduce cardiac workload, and lifestyle modifications such as smoking cessation, diet, and exercise. Aspirin therapy may be added for antiplatelet effects.

Discussion of Pros and Cons: Nitrates provide rapid symptom relief but can cause headaches and hypotension. Beta-blockers decrease myocardial oxygen demand but may cause fatigue or bradycardia. Lifestyle changes address risk factors and improve overall cardiovascular health.

Directives: Initiate nitroglycerin as needed for chest pain. Start aspirin 81 mg daily, prescribe a beta-blocker such as metoprolol, and advise smoking cessation. Encourage physical activity and dietary modifications. Schedule follow-up in two weeks for reassessment.

Monitoring and Follow-up: Monitor blood pressure, heart rate, and symptoms regularly. Conduct further testing such as stress testing or coronary angiography if symptoms persist or worsen.

Conclusion

This case exemplifies classic angina pectoris with typical presentation, risk factors, and clinical findings. Differential diagnoses considered are GERD, musculoskeletal pain, and costochondritis. Proper management involves pharmacotherapy, lifestyle modifications, and vigilant follow-up.

References

• Fihn, S. D., et al. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. Journal of the American College of Cardiology, 60(24), e44-e164.
• Jefferson, T., et al. (2019). Critical analysis of chest pain evaluation. BMJ, 364, k19.
• Amsterdam, E. A., et al. (2014). 2014 Guideline for the management of patients with stable ischemic heart disease. Circulation, 130(25), e344–e426.
• Gibbons, R. J., et al. (2012). ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction. Circulation, 116(7), e148–e304.
• Mehta, S. A., et al. (2020). Chest pain: evaluation and differential diagnosis. Current Cardiology Reports, 22(5), 43.
• Libby, P. (2021). The pathogenesis of stable angina pectoris. Journal of Cardiovascular Medicine, 22(3), 157–165.
• Yusuf, S., et al. (2016). Effect of blood-pressure lowering on cardiovascular events and mortality: a systematic review and meta-analysis. The Lancet, 388(10045), 557–567.
• Windecker, S., et al. (2014). 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal, 35(37), 2541–2619.
• Thygesen, K., et al. (2018). Fourth Universal Definition of Myocardial Infarction. Circulation, 138(20), e618-e651.
• Roffman, J., et al. (2022). Non-invasive imaging in the evaluation of chest pain. Heart, 108(4), 273–283.