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Patient with chest pain by Mind Map: Patient with chest pain
0.0 stars - reviews range from 0 to 5

Patient with chest pain

Family history

No diseases run in the family

His dad had a heart attack at 64

Introduction

Greeted the patient

Introduced myself and the team

Took the patient's date of birth

Abdulkareem Sami

He said he's 27

His birthday does not match, 12-3-1407 = 15-11-1986, 25 years old

The patients general look

Smiling

Cooperative

Looks healthy and young

Good clothing

No face discolouration or jaundice

Normal hand shake

Chief complaint

What seems to be the problem?

Chest pain, and he's worried it's from his heart

History of present complaint

Pain assessment (SOCRATES)

Site, Middle of the chest

Onset, Does not remember, it was usual then it got worse in the last 2 weeks

Character, Sharp, stabbing pain

Radiation, None

Associated symptoms, Difficulty taking deep breath

Timing, 30 minutes episodes, comes twice a week

exacerbating and relieving factors, None Mentioned

severity, Sever (8 out of 10)

effects on life style, Stops him during work to take a rest during the attacks

FIFE

The patient is worried

He thinks he might have a heart problem because his dad had one, and because he smokes

The pain affects his functioning a little, as he has to take a rest during the pain attack when he's at work

Past medical history & surgery

None

Drug history

Only multiple vitamins supplement, 1 pill a day

Forgot to ask about allergies!!

Social and occupational history

Understanding the patient's context & social history

Occupation, Banker

Diet, Regular diet

Exercise, Does aerobic exercise 3-4 times a week

Relationship statues, Married with no children

Home life, Lives with his wife with no problems

Leisure activities, Travelling in vacations, Canada, Europe, Indonesia, Dubai

Substance misuse, Tobacco (15 cigarettes a day), Alcohol, gets drunk twice a week in parties, Cannabis in parties too

Sexual history, No other partners, only his wife

Systematic inquiry

General symptoms

Well being

appetite

wight change

sleep

Cardio

No chest pain on exertion

Respiratory

Shortness of breath when taking deep breath during the pain attack

No cough

No wheeze

Gastrointestinal

No Nausea or vomiting

No indigestion

No heartburn

No abdominal pain

No change in bowl habit

Genitourinary

regular urine habits

No difficulty starting or dribbing

No multiple Sexual partners

Neurological

No headaches

No dizziness

No faints or blackouts

No weakness

Musculoskeletal

No Joint pain, stiffness or swelling

No Mobility problems

Skin

No skin rash

Endocrine

No Heat or cold intolerance

No change in sweating

No excessive thirst

Impression

Isolated musculoskeletal chest pain syndromes

This diagnosis is support by - The localised chest pain which is exacerbating with deep breath (which makes it difficult to take a deep breath). - The absence of any other symptoms that may indicate cardiovascular, respiratory, GI or other issues.

Costochondritis fits

Differential diagnosis

Cardia causes

Pulmonary causes

GI causes

Skin and sensory nerves

Rheumatic disease

Non-rheumatic systemic disease

Psychogenic causes

Plan

Ruling out life-threatining diseases

Confirming Musculoskeletal pain

Personal reflection over the experience

Was a great start and a pleasant experience. I think I did will and only forgot to ask about the allergies

For improvement I must not use my list to remind me of some points, although I maintained good eye contact

I enjoyed my time

Asked about date of birth and found he's lying

Good communications skills and eye contact

Asked about alcohol, drugs, sex, life stressors

Summarized