Attached:

health history questions

physical asssesment

key findings

differential diagnosis

primary diagnosis

tests to order

History of Present Illness (HPI) and Symptoms:

1. Question: How long does your chest pain last?
   Response: I would say less than 5 minutes, maybe only 2 or 3 minutes if I immediately stop and rest.
2. Question: Where more precisely is the pain in your chest?
   Response: It’s all over my chest, not one place in particular.
3. Question: Does anything make the pain in your chest better or worse?
   Response: When I walk too fast it seems to make it worse. When I stop and take a rest, it goes almost completely away within 3–5 minutes.
4. Question: What treatments have you had for the pain in your chest?
   Response: No medications. I just take little rest breaks which seem to help it go away.
5. Question: Are you short of breath?
   Response: Yes, sometimes, especially when my chest pain starts up.
6. Question: How long does your shortness of breath last?
   Response: It comes and goes with the chest pain. So about 3–5 minutes if I rest.
7. Question: Does anything make your shortness of breath better or worse?
   Response: Walking and doing heavy house cleaning seem to make it worse. If I sit down and rest, it seems to go away.
8. Question: What treatments have you tried for your shortness of breath?
   Response: Just resting, which helps.

HPI and Symptoms

1. How long does your chest pain last?
   “I would say less than 5 minutes, maybe only 2 or 3 minutes if I immediately stop and rest.”
2. Where more precisely is the pain in your chest?
   “It’s all over my chest, not one place in particular.”
3. Does anything make the pain in your chest better or worse?
   “When I walk too fast, it seems to make it worse. When I stop and take a rest, it goes almost completely away within 3–5 minutes.”
4. What treatments have you had for the pain in your chest?
   “No medications. I just take little rest breaks which seem to help it go away.”
5. Are you short of breath?
   “Yes, sometimes, especially when my chest pain starts up.”
6. How long does your shortness of breath last?
   “It comes and goes with the chest pain. So about 3–5 minutes if I rest.”
7. Does anything make your shortness of breath better or worse?
   “Walking and doing heavy house cleaning seem to make it worse. If I sit down and rest, it seems to go away.”
8. What treatments have you tried for your shortness of breath?
   “Just resting, which helps.”

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