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
Review of Systems
General
: Chills as noted in History of Present Illness. She thought she had a fever but did not take her temperature.
Skin
: Noncontributory
HEENT
: No recent URI symptoms.
Pulmonary
: As per History of Present Illness.
Cardiovascular
: Chest pain as per History of Present Illness. No palpitations or syncope. She has noted dyspnea with climbing stairs since chest pain began; dyspnea resolves quickly with rest and is not worsened by lying flat.
Gastrointestinal
: No abdominal pain, nausea, or vomiting. Appetite and bowel movements are normal.
Genitourinary
: Minimal spotting after recent menses.
Musculoskeletal
: She has no current musculoskeletal symptoms, although she has noted intermittent left leg swelling and discomfort for the past year. There is no history of injury or recent immobilization. The last time she had swelling and discomfort in her left leg was about 10 days ago.
Neurologic
: Noncontributory
Psychiatric
: Noncontributory
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