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 Result 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Chest Pain in a 49-yr-old Woman
Physical Examination
General appearance
: Appears anxious and in some pain. No cyanosis or respiratory distress.
Vital signs
:
Temperature 36.8° C
Pulse 107 beats/min
BP right arm 130/72 mm Hg
Respirations: 16/min
O
2
saturation 96% on room air
Skin
: No lesions or rashes.
HEENT
: Mucus membranes moist, no oral lesions, patent nares.
Pulmonary
: Lungs clear to auscultation bilaterally. No crackles or wheezes.
Cardiovascular
: Elevated rate, regular rhythm. No murmurs, rubs, or gallops. No tenderness to palpation. No jugular venous distention. Normal carotid pulse.
Gastrointestinal
: bdomen nontender and nondistended with normal bowel sounds.
Genitourinary
: Uterus palpated just below the umbilicus. No blood in vaginal vault.
Musculoskeletal
: No joint deformity, full range of motion without pain. Lower extremities: no swelling, erythema, or tenderness.
Neurologic
: Cranial nerves intact; muscle strength and sensation intact throughout.
Mental status
: Alert and oriented to person, place, and time.
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