1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. relevant vascular anatomy
1.2.1.1. coronary arteries vascular anatomy
1.2.1.2. lower extremity vascular anatomy
1.2.2. ischemic heart disease
1.2.2.1. causes
1.2.2.1.1. is it atheroscelorosis ??
1.2.2.1.2. cardiac X syndrome
1.2.2.2. risk factors
1.2.2.2.1. modified
1.2.2.2.2. non modified
1.2.2.3. mechanism
1.2.2.4. diagnosis
1.2.2.4.1. history and physical examination
1.2.2.4.2. ECG
1.2.2.4.3. labrotary
1.2.2.4.4. radiological
1.2.3. calf muscle cramp
1.2.3.1. prepheral artery disease
1.2.3.1.1. in lower extremity
1.2.3.1.2. causes
1.2.3.1.3. risk factors
1.2.3.1.4. mechanism
1.2.3.1.5. diagnosis
1.2.3.2. is there other causes
1.2.3.2.1. leg trauma
1.2.3.2.2. thrombosis
1.2.3.2.3. OA
1.2.3.2.4. restless leg syndrome
1.2.3.2.5. hypocalcimeia and hypokalemia
1.3. 30 minutes
1.3.1. The scribe does not have to write in this step!
2. Step 8
2.1. Diagnostic decision
2.1.1. widespread atheroscelorsis affecting two organs
2.2. Mechanism
2.3. Presentation
2.4. Supporting data
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. chest pain
3.1.1.1.1. started from 3 months
3.1.1.1.2. radiate to jaw and arm
3.1.1.1.3. reduced by rest
3.1.1.1.4. both are getting worse during the last 3 months
3.1.1.1.5. activity became is so limited
3.1.1.1.6. there is no associated symptoms
3.1.1.1.7. central chest pain, heaviness in nature usually during activity
3.1.1.1.8. he come because of his wife
3.1.1.2. cramp
3.1.1.2.1. started from 6 months
3.1.1.2.2. reduced by rest
3.1.1.2.3. his foot are always cold
3.1.1.2.4. excerbate by moving
3.1.2. Previous medical / surgical history
3.1.2.1. he had a previous attack before 6-8 years
3.1.2.2. fairly healthy
3.1.2.3. he thinks that cholesterol was around 5.5 at age 70
3.1.2.4. NO DM or hypertension
3.1.2.5. appendictomy at age 14 .. and broken right arm at age 20
3.1.2.6. no previous trauma
3.1.3. Drug history / allergy
3.1.3.1. no medication
3.1.3.2. no allergies
3.1.3.3. no
3.1.4. Family history
3.1.4.1. father died of heart attack by age 80
3.1.4.2. his brother did a coronary bypass surgery at age 70
3.1.5. Social / occupational history
3.1.5.1. smoker .. heavy, 25 cig per day since age 20
3.1.5.2. 1-2 small glasses of wiskey .. red wine occasionally
3.1.5.3. he gets angry quickly, and he gets angina when get angry
3.1.5.4. no finincial stress
3.1.5.5. married with 2 children
3.1.5.6. his diet contains meets , fruit and vegetables, dairy products and does/t eat fast food
3.1.5.7. he stopped smoking after the attack for 6 months and he got the attack
3.1.6. Systemic review
3.1.6.1. no headache or dizziness .. CNS is fine
3.1.6.1.1. no visual abnormality
3.1.6.2. Resp
3.1.6.3. GIT
3.1.6.4. renal
3.1.7. Physical examination
3.1.7.1. vital signs
3.1.7.1.1. 175 cm
3.1.7.1.2. 71 kg
3.1.7.1.3. pulse is 82
3.1.7.1.4. BP 140/82
3.1.7.1.5. RR 14
3.1.7.1.6. temp not mention
3.1.7.2. inspection
3.1.7.2.1. comfortable at risk
3.1.7.2.2. not disstressed
3.1.7.2.3. nicotine stains at the hand
3.1.7.2.4. no radial or brachial pulse
3.1.7.2.5. at the neck, the carotid pulse is regular with no buries
3.1.7.3. palpation
3.1.7.3.1. apex beat is normal
3.1.7.3.2. no finding
3.1.7.3.3. femoral pulse was reduced at the right with bruies
3.1.7.3.4. dorsalis pedis was reduced in the left and not pulbable at the right
3.1.7.3.5. posterior tibial pulse also reduced in the left and not palpable at the right
3.1.7.4. auscultation
3.1.7.4.1. crackles and wheez in the base
3.1.7.4.2. heart sounds are normal
3.1.8. tests results
3.1.8.1. ECG
3.1.8.1.1. pathologic Q waves at leads 2,3 and AVF
3.1.8.2. Cholesterol
3.1.8.2.1. 5.7 .. elevated
3.1.8.3. exercise ECG
3.1.8.4. ultrasound
3.1.8.5. catherisation
3.1.8.6. CBC notmal
3.1.8.7. biochemistry and electrolytes are normal