History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Essential Immediate Steps
Test Result 1
Test Interpretation
Relevant Testing
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Chest Pain in a 62-yr-old Man
Physical Examination
General
: appearance Middle-aged male in no apparent distress.
Vital signs
:
Temperature: 37.2° C
Pulse: 76 beats/min
BP: 162/86 mm Hg
Respirations: 14/min
Skin
: No rashes or lesions.
HEENT
: Oropharynx clear
Pulmonary
: Lungs clear to auscultation bilaterally. No wheezing, rhonchi, or rales.
Cardiovascular
: Regular rate and rhythm, normal S
1
and S
2
. No murmurs, rubs, or gallops. Brisk carotid upstrokes ; all pulses 2+ and symmetrical bilaterally. No neck vein distention visible when patient is sitting at 45°.
Gastrointestinal
: Soft, nontender, nondistended abdomen; audible bowel sounds.
Genitourinary
: Unremarkable
Musculoskeletal
: Chest pain not reproducible with palpation. No lower-extremity edema, swelling, or tenderness.
Neurologic
: Unremarkable
Mental
: status Unremarkable
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