Case 3

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Case 3: A 75-year-old female with chest pain
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Additional Subjective Data
When assessing a patient with chest pain, it is crucial to gather comprehensive subjective
data. In addition to the provided information, inquire about the following is important:

Onset and Duration: Ask the patient when the chest pain started, its duration and
whether it is constant or intermittent.

Character of Pain: Determine if the pain is sharp, stabbing, dull, aching, or burning.
Also, ask if it radiates to other areas such as the arm, jaw, or back.

Triggers and Alleviating Factors: Explore if any activities or positions worsen or
relieve the pain.

Associated Symptoms: Inquire about other symptoms like shortness of breath, nausea,
sweating, or dizziness.

Medical History: Gather a detailed medical history, including any history of heart
disease, hypertension, diabetes, or previous chest pain episodes.

Medications: Ask about the patient’s current medications, especially if they are taking
any anticoagulants or antiplatelet drugs.
Additional Objective Findings
In a chest pain assessment, a thorough physical examination and additional objective
findings are necessary, including:

Cardiovascular Assessment: Listen for any abnormal heart sounds, such as murmurs or
extra heart sounds. Assess for irregular rhythms, and palpate for thrills or heaves.

Respiratory Assessment: Evaluat …
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