Heart Disease Program Diagnosis

Diagnosis Results for on case 3 at 13:49 Dec 9, 1998

Patient Name:

Patient: PT3 Note: DOB 10/10/1932 Description: angina

• History
  • age: 64 year old
  • sex: male
  • weight: normal
  • dyspnea: no
  • chest-pain: anginal chest-pain at-rest for 4hr
  • symptoms:
  • therapies: on nothing
• Vital-Signs
  • blood-pressure: 120/80
  • heart-rate: 80
  • resp: 22
  • temp: 97.7
• Physical-Exam
  • mental-status: conscious
  • chest: was clear
  • jugular-pulse: normal
  • auscultation: diminished-heart-sounds
  • abdomen: normal
  • extremities: normal
• Laboratory-Findings
  • ekg: (1hr): sinus-rhythm, acute lateral infarct and anterior ischemia inferior ischemia
  • cxr: : wnl
  • blood-chemistry: (1hr): Na: 138 k: 3.6 bun: 8 creat: 0.6
  • cbc: (1hr): hct: 40 wbc: 11.4
  • urinalysis: (1hr): sg: 1.014
  • cardiac-enzymes: normal-cpk-mb (1hr)

BEST DIAGNOSTIC HYPOTHESIS

• NONPULMONARY INFECTION as indicated by TACHYPNEA (R: 22), wbc 1hr: 11.4, although fatigue not present
• UNSTABLE ANGINA (caused by CORONARY ARTERY DISEASE) as indicated by ekg 1hr: inferior ischemia, ekg 1hr: anterior ischemia, EKG: acute infarct, anginal chest pain at rest
• CORONARY ARTERY DISEASE as indicated by causing UNSTABLE ANGINA

Explanation of items in other hypotheses:

• MYOCARDIAL INFARCTION RECENT (caused by CORONARY ARTERY DISEASE) as indicated by ekg 1hr: anterior ischemia, ekg 1hr: inferior ischemia, EKG: acute infarct, wbc 1hr: 11.4
• MYOCARDIAL INFARCTION ACUTE (caused by CORONARY ARTERY DISEASE) as indicated by ekg 1hr: inferior ischemia, ekg 1hr: anterior ischemia, anginal chest pain at rest, EKG: acute infarct, wbc 1hr: 11.4, although increased cpk mb not present, diaphoresis not present
• CORONARY SPASM as indicated by causing MYOCARDIAL INFARCTION RECENT, causing UNSTABLE ANGINA

The findings (lower case) are explained by the hypotheses as follows:

• MYOCARDIAL INFARCTION ACUTE explained by CORONARY ARTERY DISEASE.
• UNSTABLE ANGINA and MYOCARDIAL INFARCTION RECENT explained by CORONARY SPASM or CORONARY ARTERY DISEASE.
• anginal chest pain at rest explained by MYOCARDIAL INFARCTION ACUTE or UNSTABLE ANGINA.
• ekg 1hr: inferior ischemia, ekg 1hr: anterior ischemia and EKG: acute infarct explained by MYOCARDIAL INFARCTION ACUTE, MYOCARDIAL INFARCTION RECENT or UNSTABLE ANGINA.
• wbc 1hr: 11.4 explained by MYOCARDIAL INFARCTION ACUTE, MYOCARDIAL INFARCTION RECENT or NONPULMONARY INFECTION.
• TACHYPNEA (R: 22) explained by NONPULMONARY INFECTION.
• R: 22 is unaccounted.