Chest Pain

Nurse Practitioner Diagnosis- Chest Pain.


Don't use plagiarized sources. Get Your Custom Essay on
Chest Pain
Just from $13/Page
Order Essay






One Page Only

Please use attachment only. Copy and paste it into *SOAP*

I OSCE1-Chest Pain attached and copy and paste into the temple.

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 1



OSCE 1: Chest Pain 


This video format is designed to help you prepare for objective structured clinical examinations, or 


You are going to observe and participate in a clinical encounter of a patient who comes to the office 

with a complaint of chest pain.  

As you observe the encounter, you will be asked to answer questions while the image on the screen 

freezes. Such questions will allow you to practice history taking and physical examination skills as well as 

your clinical reasoning skills in developing an assessment or differential diagnosis and a plan—that is, an 

appropriate next diagnostic workup. 

You will have time to record your findings and receive feedback. 


Health History 

Tell me your special concerns today. 

I’m a little worried because I have been having sharp pains in my chest for the last two weeks. 

What findings might be important to look for as you observe this patient? 

Level of distress. 

Labored breathing. 

Skin color: central and peripheral cyanosis. 

Respiratory rate. 

Two weeks ago I was reading a story in the paper about a car crash, when I noticed sharp pains in my 

left chest. I was sweating and short of breath for about 5 minutes. And my heart felt like it was racing. 

What possible causes of chest pain are you considering?   



Panic attack. 

Musculoskeletal chest wall pain. 

Can you tell me how severe the pain was, on a scale from 1 to 10, with 1 being very faint and 10 being 


Downloaded From: by a Molloy College User on 01/17/2020

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 2 

I was 5 over 10.   


Did it move into your neck or down your left arm? 

No, no it was just in my chest. 

How have you been since then? 

I’ve had two other episodes, one of them was about 10 days ago when I was lifting some books, the 

other was about 5 days ago when I was talking with my sister about our father’s death.  He died 3 

months ago in a car crash. 

Did you have any other symptoms when you had these chest pains? 

Yes, I had the same sweating and shortness of breath, with some light‐headedness during the most 

recent one. 

What was the level of pain? 

The same, about 5 out of 10 for about 5 minutes. Then the pain just went away while I was sitting there. 

I keep feeling so lost and panicked since my father died. 

How are you feeling today? 

Today I’m feeling fine, but I haven’t been sleeping well. It’s strange, I never felt anxious or depressed 


What cardiovascular risk factors do you need to consider in this patient? And which one has the highest 

risk for coronary artery disease? 

The risk factors are: 

Family history of coronary artery disease. 

Hyperlipidemia, hypertension, smoking, diabetes. 

For women, preeclampsia and collagen vascular disease.   

Family history conveys highest risk.   

Do you have any problems with acid reflux? Or have you done any heavy lifting or strenuous exercise? 

No, I’ve never had any stomach problems and I don’t really exercise much. 

Do you have a history of high blood pressure? I noticed today your blood pressure was 140 over 95. 

Yes, well I did have high blood pressure during my three pregnancies, I think it was about 145 over 90, 

but the deliveries were fine. 

What about smoking?  

Downloaded From: by a Molloy College User on 01/17/2020

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 3 

When I was in my 20s I smoked about a pack a day for about 4 years. 

Do you drink any alcohol?  

I have 1…or 2 glasses of wine maybe 3 nights a week, more recently to help me relax. 

Is there any heart disease in your family? 

Yes, my brother had bypass surgery when he was 48, and my mom died of a heart attack when she was 


What about high cholesterol, or is there any diabetes in the family? 

No, I’ve never had trouble with my cholesterol and we don’t have diabetes in my family. 

You’ve given me a good picture of your symptoms, and I can see why you’re concerned. Is there 

anything you think we may have missed?   

No, but I can’t get away from these flashbacks about my father’s accident. 

It’s common to visualize scenes like a crash with a loved one. Let’s do your physical examination, and 

then we can talk more. 


Physical Examination 

I see your blood pressure is 150 over 95 and your heart rate is 95 today. These are both somewhat 

elevated. I would like to begin by examining your lips and nails for color and then listen to your lungs.           


Examine lips and nails for cyanosis. 

Okay, looks good. 

Percuss then auscultate posterior lungs in ladder pattern. 

Take a deep breath. 

Listen to the lungs making sure to listen to the right middle lobe under axilla. 

One more time. 


I’ll be examining the vessels in your neck, and then your heart. So please lie back with your feet straight 


Examine the neck first. 

Assess the jugular venous pressure. 

Downloaded From: by a Molloy College User on 01/17/2020

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 4 

Find the highest point of oscillation in the internal jugular vein… 

…and measure the vertical distance from the sternal angle. 

Palpate carotid upstroke.  

The normal upstroke is brisk, smooth, and rapid, and follows S1 almost immediately. 

Large bounding upstrokes indicate aortic insufficiency. 

Listen for a bruit, which is a whooshing, murmur‐like sound often from atherosclerotic narrowing of the 

carotid artery. A bruit sounds like this: 


Okay, I’m going to check the tapping impulse point of your heart.  

Palpate the point of maximal impulse. You can do this and listen to the heart sounds by listening under 

the gown without exposing the chest.  

You may notice “tapping” which is timed at the beginning of systole. The point of maximal impulse may 

be sustained or diffuse, meaning spread over more than one intercostal space. 

Listen for S1 and S2 in each of the six listening areas: in the aortic area in the right second interspace 

close to the sternum; in the pulmonic area in the left second interspace close to the sternum; in the left 

third interspace; in the tricuspid area in the left fourth and left fifth interspaces; and in the mitral area at 

the apex.      

Use the diaphragm at the right upper sternal border and the lower left sternal border. 

Use the bell at the apex. 

Listen to and palpate the abdomen. 

The following findings may be heard in the cardiac auscultation of this patient. Can you identify these 

heart sounds? 


S4 is a low pitched diastolic sound reflecting changes in ventricular compliance, best heard with the bell 

with the patient in a left lateral decubitus position. It may be present during ischemia or in the setting of 


Identify these heart sounds. 


Mitral regurgitation is a holosystolic murmur reflecting mitral valve dilatation, best heard at the apex 

that may radiate to the axilla and lower left sternal border. It may occur with transient ischemia. 

Downloaded From: by a Molloy College User on 01/17/2020

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 5 

Assess congestive heart failure (CHF) in patients with extensive myocardial infarction that compromises 

cardiac output due to decreased stroke volume or heart rate. Which findings on the cardiac exam have 

the best evidence for congestive heart failure?  

Rales, an elevated JVP, and an S3 consistently predict heart failure. 


S3 is a low‐pitched diastolic sound reflecting changed ventricular compliance, best heard with the bell 

with the patient in a left lateral decubitus position.  

Palpate the ankles for edema. 


Diagnostic Considerations 

List your diagnostic considerations in order of importance and explain your rationale. 

Press pause and list your answers. Resume when you are ready to receive feedback. 

Angina. This woman has stress‐induced non‐exertional chest pain. Recent evidence shows that women 

present with more subtle symptoms of cardiovascular disease. She has cardiac risk factors of 

hypertension, past smoking, preeclampsia, and family history. 

Panic attack. She had stress related symptoms and flashbacks to the recent death of her father in a car 

accident. She has suggestive anxiety, chest pain, and diaphoresis. 

GERD.  Her alcohol intake has recently increased. She has some reflux symptoms but her symptoms are 

not triggered by meals and she does not report heartburn. 

Musculoskeletal chest wall pain. There is no history of chest pain triggered by movement of the upper 

torso or related exercise, and no notation of chest wall tenderness. 

Dissecting aortic aneurysm. There is no asymmetry of blood pressures noted and no history of pain 

shooting into the neck, up the side of the head, or into the back. 


Diagnostic Workup 

List 5 next steps in your diagnostic workup. 

Press pause and list your answers. Resume when you are ready to receive feedback. 

EKG. About 80% of patients with an acute MI have an initial EKG that shows evidence of new infraction 

or ischemia, if read correctly. However, among patients mistakenly discharged from the emergency 

department, up to 50% have normal or non‐diagnostic EKG findings.   

Stress echo. This is the test of choice for women with atypical chest pain. The echocardiography stress 

test has a sensitivity of 90% and specificity of 79% for women, and 85% and 96% for men. 

Downloaded From: by a Molloy College User on 01/17/2020

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.  Page 6 

Consider a trial of a proton pump inhibitor for 4‐6 weeks for possible GERD. 

Chest x‐ray may be helpful to look for widened mediastinum, which can be evidence of aortic dissection. 

Behavioral therapy—to learn management strategies for anxiety and panic disorder. 



In sum, this is a 50‐year old school counselor with three episodes of left substernal chest pain over the 

prior two weeks, rated 5 to 10 in intensity, with associated sweating and shortness of breath.   

The first episode was precipitated by reading about a car crash, the cause of her father’s recent death. 

The patient had hypertension during pregnancy and a brief smoking history in her 20s.   

There is a strong family history of coronary artery disease. Her mother died of a myocardial infarction at 

age 62 and her brother had a coronary bypass at age 48.   

There is no history of diabetes. Her physical examination is unremarkable except for her blood pressure 

of 150 over 95.   

The differential diagnosis includes angina, especially suspect due to her symptoms, history of 

hypertension during pregnancy, and family history. It also includes panic attack, GERD, musculoskeletal 

chest pain, and dissecting aortic aneurysm.   

The diagnostic workup includes an EKG, stress echo, trial of a PPI, chest x‐ray, and behavioral therapy. 

Downloaded From: by a Molloy College User on 01/17/2020

SOAP Note Template

– The “history” section

HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient).

Pertinent past medical history.

Pertinent review of systems, for example, “Patient has not had any stiffness or loss of motion of other joints.”

Current medications (list with daily dosages).

– The physical exam and laboratory data section

Vital signs including oxygen saturation when indicated.

Focuses physical exam.

All pertinent labs, x-rays, etc. completed at the visit.

Assessment/Problem List
– Your assessment of the patient’s problems

Assessment: A one sentence description of the patient and major problem

Problem list: A numerical list of problems identified

All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.”

Provide at least 2 differential diagnoses for the major new problem identified in your note.

– Your plan for the patient based on the problems you’ve identified

Develop a diagnostic and treatment plan for each differential diagnosis.

Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc.

Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.).

Also see your Bates Guide to Physical Examination for excellent examples of complete H & P and SOAP note formats.

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.


Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.


Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.


Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

All samples
Essay (any type)
Essay (any type)
The Value of a Nursing Degree
Undergrad. (yrs 3-4)
View this sample

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.


Happy Clients


Words Written This Week


Ongoing Orders


Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success


We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now

Order your essay today and save 30% with the discount code Happy