History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Essential Immediate Steps
Test Result 1
Test Interpretation
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Chest Pain in 74-Yr-Old Man
Physical Examination
General appearance
: Well-developed elderly African-American man in minor distress.
Vital signs
:
Temperature: 36.3° C
Pulse: 110 beats/min
Right Arm: 142/84 mm Hg
Left Arm: 142/80 mm Hg
Respirations: 20/min
Oxygen saturation: 96% on room air
Skin
: Slight pallor. No cyanosis. Cool, dry to the touch.
HEENT
: Clear oropharynx. No cervical lymphadenopathy. Normal carotid upstrokes.
Pulmonary
: Normal effort. Decreased breath sounds bilaterally with prolonged expiratory phase. No crackles or wheezes noted.
Cardiovascular
: No jugular venous distention at 45°. Regular rhythm and rate. Point of maximal impulse (PMI) not displaced. S
1
decreased, S
2
normal. Grade 1-to-2, soft, early systolic murmur heard at the apex. S
4
present. No rubs or gallops. No peripheral edema.
Gastrointestinal
: Normal bowel sounds. No epigastric tenderness.
Genitourinary
: No costovertebral angle tenderness.
Musculoskeletal
: Unremarkable; no erythema, tenderness, or swelling in the legs.
Neurologic
: Alert and oriented x 3. No focal motor or sensory deficits.
Mental status
: Appropriate mood and behavior.
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