Chest Pain and Dyspnea: Diagnostic Reasoning in Primary Care CASE STUDY 2

Ms. L.T. is a 61-year-old female presenting with intermittent chest tightness and exertional dyspnea for 3 weeks.

History:

· PMH: Hypertension, tobacco use (30 pack-years), anxiety

· Medications: Amlodipine 5 mg daily

· Symptoms: Chest discomfort radiating to jaw, relieved by rest

Vitals:

· BP: 156/88 mmHg

· HR: 96 bpm

Initial Findings:

· EKG: Nonspecific ST-T changes

· SpO₂: 95% on room air

Student Assignment Requirements

1. Pathophysiology (25%)

· Compare and contrast ischemic vs non-ischemic chest pain mechanisms

· Explain cardiopulmonary causes of dyspnea

· Address anxiety overlap

2. Assessment & Differential Diagnosis (35%)

· Focused cardiac and pulmonary exam

· Prioritized differential diagnosis

· Identification of life-threatening conditions

· Decision-making for ED referral vs outpatient management

3. Pharmacology & Initial Management (30%)

· Acute and chronic pharmacologic considerations

· Antihypertensive optimization

· Risk reduction strategies

· Follow-up testing and referrals

4. APA & Evidence Integration (10%)

RUBRIC – CASE STUDY 2 – Chest Pain and Dyspnea Diagnostic Reasoning (100 Points)

1. Pathophysiology of Symptoms (25 points)

Level

Description

Excellent (23–25)

Clearly differentiates ischemic and non-ischemic mechanisms of chest pain and dyspnea, accurately linking physiology to patient presentation.

Satisfactory (18–22)

Correct explanation of major mechanisms with limited depth or integration.

Unsatisfactory (13–17)

Partial or unclear explanation of pathophysiology.

Poor (1–12)

Incorrect or superficial explanation of mechanisms.

Not Submitted (0)

Section not submitted or missing.

2. Assessment & Differential Diagnosis (35 points)

Level

Description

Excellent (33–35)

Thorough, prioritized differential diagnosis with clear identification of life-threatening conditions and appropriate disposition decisions.

Satisfactory (26–32)

Appropriate differential but limited prioritization or incomplete reasoning.

Unsatisfactory (18–25)

Incomplete or poorly prioritized differential diagnosis.

Poor (1–17)

Unsafe or inaccurate diagnostic reasoning.

Not Submitted (0)

Section not submitted or missing.

3. Pharmacology & Initial Management Plan (30 points)

Level

Description

Excellent (28–30)

Evidence-based management addressing acute and chronic needs with clear rationale and follow-up.

Satisfactory (22–27)

Management plan is appropriate but lacks detail or optimization.

Unsatisfactory (16–21)

Partial or unsupported management decisions.

Poor (1–15)

Unsafe or inappropriate treatment plan.

Not Submitted (0)

Section not submitted or missing.