Aquifer Internal Medicine 02: chest pain case discussion

Three bullets and two pages, so the discipline is in choosing what not to write. The first asks for the history of present illness *in preparation for the clinic visit*, and it supplies the structure explicitly: **OLDCARTS** — onset, location, duration, characteristics, aggravating factors, relieving factors, treatment, severity. Use those as your subheadings and write the actual questions you would ask under each, in the words you would use. A paragraph explaining what OLDCARTS stands for is not an answer; a list of eight questions tailored to chest pain in a woman of this age is. That also keeps the section short enough to leave room for the other two bullets. Two pages against three bullets is roughly two thirds of a page each, so the history section has to be a list rather than a narrative if the plan section is to survive.

The clinical judgement the case is testing sits underneath the mnemonic. A sixty-year-old woman with chest pain is a presentation where **atypical features are common** — fatigue, nausea, dyspnoea, back or jaw discomfort rather than crushing central pain — and where that atypicality is associated with slower evaluation and treatment. So the history questions should be built to catch a presentation that does not announce itself: ask about exertional relationship and associated symptoms explicitly rather than waiting for them to be volunteered, and record cardiac risk factors as part of the history rather than leaving them to the examination. Record what she was doing when the pain started and what stopped it, because the exertional relationship is the single most discriminating item in the whole history and it is frequently left implicit. Ask about symptoms she may not connect to her chest at all.

Keep the differential visible while you write the history, because the questions only make sense against it. Chest pain of this kind spans acute coronary syndrome, pulmonary embolism, aortic dissection, pericarditis, pneumonia, gastro-oesophageal reflux, musculoskeletal chest wall pain and panic — and several of the OLDCARTS elements exist precisely to separate them. Pain reproduced by palpation, relief with antacids, pleuritic quality, a sudden tearing onset radiating to the back: each points somewhere different. Saying which item you are asking and why is what turns a mnemonic into reasoning a marker can see. Write the differential down before drafting the questions and mark which OLDCARTS element addresses each one; anything unaddressed is a question you have not asked yet. Anything addressed twice is a question you can cut.

The second bullet has a sub-question that gets dropped: *are there any additional you would have liked to be included that were not?* That is an invitation to critique the case itself, and it is the only part of this assignment where you can demonstrate judgement beyond recall. Answering it means noticing an omission and justifying it — a missing risk score, a test not ordered, a physical finding not documented, a comparison with a prior tracing. A short paragraph naming one or two specific gaps and saying what each would have changed is worth more than a longer list of what the case did include. The honest version of this answer sometimes concludes that the evaluation was adequate, in which case say what made it so rather than inventing a gap to fill the requirement.

The third bullet is three things in one line: *what plan of care will Ms. Johnston be given at this visit; what is the patient education and follow-up*. Answer them as three. The plan is what happens now, including disposition — a clinic visit is not the right setting for every chest pain, and saying when this presentation would require escalation rather than a follow-up appointment is a legitimate and often overlooked part of the answer. Patient education should include the return precautions she leaves with, and follow-up should carry a time frame and a named contingency rather than “as needed”. Naming the specific symptoms that should bring her back, and how quickly, is what makes the education section assessable rather than reassuring.