The Rational Clinical Examination
David L. Simel, Drummond Rennie
David L. Simel, Stephen W. Goodacre, L. Kristin Newby
chest pain, myocardial infarction
"A 62-year-old woman experienced chest discomfort while walking from
the parking garage to your hospital. She decided to stop in the emergency
department for evaluation. The discomfort has been present for about
10 to 12 minutes and is creating a dull ache in her left shoulder
and arm. As you interview her, she is diaphoretic and experiencing
the chest discomfort. Her blood pressure is 145/95 mm Hg.
The lungs are clear to auscultation, whereas the cardiac examination
reveals an S4 systolic sound but no murmur. The pulses
are equal in all of her extremities. An electrocardiogram (ECG)
result seems normal, but your hospital provides neither computerized
ECG reports nor computerized estimates of the probability of a myocardial
infarction (MI). She experiences relief after a sublingual nitroglycerin
tablet. You find that she was recently diagnosed with diabetes and
systolic hypertension, and she has been trying to stop smoking.
There was no nausea with the discomfort, although she observes frequent
epigastric discomfort that responds to antacids. She takes cimetidine, which
helps with her discomfort. ..."
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