Larry M chest pain case study guide: diagnosis to plan
Larry M. — 60, hypertensive, three days past a three-minute episode of chest heaviness, dyspnea, nausea and diaphoresis he insists was nothing — through a question set demanding one primary diagnosis with ICD-10 codes, evidence-based testing, lead localization, secondary diagnoses, a JNC 8 verdict and a guideline therapy plan.
Editorial process
Last reviewed · August 12, 2026
What does Larry's three-minute episode plus new fatigue mean?
The case's tension is its teaching point: Larry feels fine and came because his wife made him, but the history he gives — three minutes of exertion-context chest heaviness with dyspnea, nausea and diaphoresis, followed by new exertional fatigue — is a textbook anginal episode in a man with hypertension, elevated LDL at 180 with an HDL of 38, obesity at a BMI of 33.5, and a laterally displaced PMI with mild JVD suggesting his hypertension has already remodeled the heart. The first question forces commitment: one primary diagnosis with ICD-10 codes and explicitly no differentials, which rewards reading the episode plus the new exertional intolerance as unstable angina or an anginal syndrome needing urgent evaluation rather than hedging across possibilities. Whatever you commit to, code it properly — the ICD-10 requirement is a competency check, and the coding reference exists to be used rather than guessed from memory.
The testing question sets its own standard — every test linked to Larry's specific case with evidence-based support, or a defended decision that no testing is warranted (not a live option here): a 12-lead ECG immediately, troponins given the three-day-old episode, and the risk-stratified pathway the chest-pain evaluation literature lays out, with a lipid panel refresh and metabolic baseline earning their places from his own labs. The ST-depression lead question is a focused ECG-literacy check — answer it as lead territories (which leads look at which walls, and what depression in them localizes) rather than reciting definitions. The secondary-diagnoses question is where the chart's quiet findings pay: uncontrolled hypertension at 146/90, dyslipidemia on the three-month-old labs, obesity, the periodontal disease his poor dentition shows, tobacco and alcohol use, and the missed influenza vaccination all belong on the problem list with a plan apiece.
The therapy questions name their authorities, and precision with them is the graded skill: under JNC 8's thresholds for a patient under 60, 146/90 exceeds goal — so the verdict is yes, hypertensive and undertreated on lifestyle measures alone — and the 2017 ACC/AHA recommendations (the brief's 'ACA 2017') would stage him more severely still; the plan should pick a first-line agent with the pharmacology stated (a thiazide, calcium channel blocker, or ACE inhibitor/ARB, argued for this patient's profile) and the rationale the question demands. The primary-diagnosis plan closes the loop — cardiology referral, education that takes his minimization seriously as a adherence risk, defined follow-up, further workup and medications — anchored to one current journal article as the brief requires. Throughout, let the case's own numbers do the arguing: this chart was built so that every question's answer is already in it.
Likely learning objectives
Inferred from the brief — check these against your own rubric.
- 01Commit to a single primary diagnosis from the episode's anginal features and code it in ICD-10.
- 02Order tests linked to this case with evidence-based support — ECG, troponins, the risk-stratified pathway.
- 03Answer the ST-depression question as lead territories and localization.
- 04Assemble the secondary problem list from the chart's quiet findings, each with a plan.
- 05Apply JNC 8 and the 2017 ACC/AHA recommendations precisely, choosing a first-line agent with stated pharmacology.
Read the full question
Review every instruction before using the planning guidance that follows.
Turn the brief into deliverables
- 01The primary diagnosis with ICD-10 codes, no differentials.
- 02Case-linked labs and diagnostic tests with evidence-based support and rationale.
- 03The ECG leads demonstrating ST depression; the secondary diagnoses needing address.
- 04The JNC 8 hypertension determination and a 2017 ACC/AHA-informed therapy plan with pharmacological properties and rationale.
- 05A primary-diagnosis plan (referral, education, follow-up, further workup, medications) supported by one current evidence-based journal article.
How do the diagnosis, testing and therapy questions chain?
The episode, read honestly
Interpret the three-minute chest heaviness with dyspnea, nausea and diaphoresis — plus the new exertional intolerance — against his risk profile, and commit to the primary diagnosis with its ICD-10 codes.
The workup, case-linked
Order the ECG, troponins and risk-stratified follow-on testing, each tied to Larry's findings with the evidence base stated, alongside refreshed lipids and metabolic baseline.
Leads and the quiet problem list
Answer the ST-depression localization by lead territory, then assemble the secondary diagnoses: uncontrolled BP, dyslipidemia, obesity, dental disease, substance use, vaccination gap.
The guideline verdicts
Apply JNC 8's thresholds to 146/90 at age 60 for the hypertension verdict, then design the antihypertensive plan under the 2017 ACC/AHA recommendations with the chosen agent's pharmacology and patient-specific rationale.
The closing plan
Complete the primary-diagnosis plan: cardiology referral, education that treats his minimization as an adherence risk, defined follow-up, further workup and medications — anchored to one current journal article.
Where do the chest-pain pathway and BP guidelines live?
Recommended databases
- NCBI Bookshelf / StatPearls
- CMS (ICD-10)
- PMC (current journal article for the plan)
Search sequence
- 1.Read the chest-pain evaluation reference for the risk-stratified testing pathway the workup question wants cited.
- 2.Verify the ICD-10 codes against the coding authority rather than memory.
- 3.Check the hypertension reference for JNC 8 and 2017 ACC/AHA thresholds and first-line agents before writing the verdicts.
- 4.Find one current journal article on managing the committed diagnosis for the closing plan's required support.
Reference shortlist
These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.
Nothing here is cleared for citation until you have read it.
- 01
Chest Pain: Evaluation and Exclusion of Myocardial Infarction and Angina
StatPearls, NCBI Bookshelf · 2024
The evaluation pathway the testing question grades against — ECG, biomarkers and risk stratification for exactly Larry's presentation.
- 02
Essential Hypertension
StatPearls, NCBI Bookshelf · 2024
The guideline thresholds and first-line agent families behind the JNC 8 verdict and the ACC/AHA-informed therapy plan, with the pharmacology the question requires.
- 03
ICD-10
Centers for Medicare & Medicaid Services · 2025
The coding authority for the primary diagnosis's ICD-10 requirement — codes verified, not recalled.
Review before submission
Common mistakes
- Hedging with differentials when the question explicitly demands one committed diagnosis.
- Taking Larry's 'I feel fine' at face value instead of reading the episode-plus-new-fatigue pattern.
- Ordering tests without linking each to this case's findings and evidence, which the question's own wording requires.
- Answering the leads question with a definition of ST depression instead of lead territories.
- Missing chart-quiet secondary diagnoses — the dentition, the declined flu shot, the alcohol and cigar use.
- Citing the guidelines loosely; the JNC 8 verdict and agent choice are graded on threshold-level precision.
Submission checklist
- Primary diagnosis committed and ICD-10 coded.
- Each test linked to case findings with evidence-based support.
- ST-depression leads answered by territory.
- Secondary problem list complete with per-problem plans.
- JNC 8 verdict stated against its thresholds; therapy plan with pharmacology, rationale and a current journal citation.
Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.
Written by
Aaron Bishop
MA, Education
assignment interpretation and research-methods coaching across disciplines
Aaron leads the EssayCrackers editorial desk. He works on how assignment briefs are read — what a rubric is actually asking for, and where students most often answer a different question than the one set.
Reviewed by
Dr. Nathan Cole
PhD, Rhetoric & Composition
Argumentation and thesis development
Nathan teaches first-year composition and directs a university writing center. He reviews EssayCrackers guides for argumentative soundness and citation accuracy.