Florence Blackman iHuman Case Study

Florence Blackman is a 66-year-old female presenting with intermittent squeezing chest pain that occurs with exertion and radiates to her left arm.

In this comprehensive guide, we’ll walk you through how to approach her case, from initial history-taking through physical examination to the final diagnosis of stable angina and coronary artery disease. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this cardiovascular case simulation.

Florence Blackman Ihuman Case Overview (Doorway Information)

Patient Overview: Florence Blackman is a 66-year-old Caucasian female presenting with a chief complaint of “intermittent squeezing chest pain” that has been occurring over the past 2 weeks. She describes experiencing exertional mid-chest pain with a “squeezing feeling” that radiates to her left arm, particularly when skiing cross-country in cold weather. The pain is accompanied by dyspnea on exertion and is consistently relieved by rest.

Key Background Information:

• Age/Gender: 66-year-old female
• Chief Complaint: Intermittent squeezing chest pain
• Duration: 2 weeks of symptoms
• Pain Characteristics: Exertional, radiates to left arm, relieved by rest, worse in cold
• Associated Symptoms: Dyspnea on exertion
• Significant History: Hypertension, hyperlipidemia, former smoker (quit 15 years ago), family history of heart disease
• Current Medications: Hydrochlorothiazide (HCTZ) 12.5mg daily
• Occupation: Marketing executive with demanding work schedule
• Lifestyle: Active with regular aerobic exercise, but reports high stress levels

The patient appears alert and oriented, currently pain-free at presentation, with stable vital signs. Her presentation is classic for cardiac-related chest pain, making this an excellent case for learning systematic cardiovascular assessment and differential diagnosis skills.

Florence Blackman (66 y/o female) – Chest Pain Assessment

• CC: Intermittent squeezing chest pain
  • MSAP: Exertional “squeezing” mid-chest pain radiating to left arm, relieved by
  rest, worse with cold
  • Associated dyspnea on exertion
  • History: HLD, HTN, previous smoker, family hx of heart disease
  • Stressful work
  
• History Questions:
  − How can I help you today?
  − Any other symptoms we should discuss?
  − Do you have any allergies?
  − Are you taking any OTC or herbal medications?
  − Any new or recent changes in medications?
  − What does the pain / discomfort in your chest feel like? (squeezing, pressure,
  crushing, burning, stabbing, aching, tingling, suffocating)
  − How severe (scale 1−10) is the pain in your chest?
  − Does anything make the pain in your chest better or worse?
  − What are the events surrounding the start of your chest pain?
  − Is there a pattern to your chest pain?
  − Have you had any trauma to your chest?
  − Does the pain in your chest radiate someplace else? Where?
  − Do you have unusual heartbeats (palpitations)?
  − Does the pain get worse with breathing?
  − Does your pain awaken you from your sleep?
  − Is your pain affected by what, when, or how much you eat?
  − Do you presently have heartburn, a food or acid taste in your mouth?
  − Do you drink alcohol? If so, what do you drink and how many drinks per day?
  − Do you have any of the following problems: fatigue, difficulty sleeping,
  unintentional weight loss or gain, fevers, night sweats?
  − Do you experience: SOB, wheezing, difÏculty catching breath, chronic cough,
  sputum production?
  − Does anything make your shortness of breath better or worse?
  − How long does your SOB last?
  − Do you have any of the following: heat or cold intolerance, increased thirst,
  increased sweating, frequent urination, change in appetite?
  − Do you have any of the following: dizziness, fainting, spinning room, seizures,
  weakness, numbness, tingling, tremor?
  − Do you have problems with: N/V, constipation, diarrhea, coffee grounds in your
  vomit, dark tarry stool, bright red blood in your BM, early satiety, bloating?
  − How is your overall health?
  − Tell me about your work.
  − Tell me about daily exercise or sports that you play.

Physical Exam:

• − Vitals: pulse, BP, respirations
• − Examine skin
• − Neck: measure JVP (jugular venous pressure)
• − Neck: auscultate carotid arteries
• − Chest wall & lungs:
• o Visual inspection of anterior & posterior chest
• o Palpate anterior & posterior chest
• o Auscultate lungs
• − Heart:
• o Palpate for PMI (Point of Maximal Impact)
• o Auscultate heart
• − Abdomen:
• o Auscultate abdominal/femoral arteries
• o Palpate abdomen
• − Extremities: Visual inspection of extremities

Assessment note:

F.B. is a 66 y/o Caucasian female presenting with 2−week h/o new onset, intermittent, stable chest pain which radiates to the L arm, occurs with SOB, is worse with cold temperatures and exertion, and improved by rest. On physical exam she is pain free with stable vital signs. PMH risk factors include: distant history of smoking (5 pack/years), a history of HTN, high cholesterol, and a family history of coronaryvascular disease

Stress test: 2−mm ST segment depression in inferior leads, 2, 3, and aVF and V3−6

Diagnosis: Coronary artery disease: stable angina

Plan:

• − Determine need for coronary angiography based on stress test results and ECHO.Her Duke score of 10.5 is slightly above moderate risk, and arguments could be both a trial at medication intervention since the pt needs improvement on both HTN and HLD
• Augment management of preexisting HTN and HLD with a BB (metoprolol 25 mg XR daily); a statin (atorvastatin 40 mg daily); and ASA 81 mg daily
• Continue use of HCTZ 25 mg daily
• Encourage lifestyle modification:
• Decrease the intensity of aerobic workouts for the next 3 months
• D/c alcohol for the next 2 months as I start a statin
• f/u in 3−4 weeks

Florence Blackman SOAP Note

Patient: Florence Blackman Subjective Data

CC: 66-year-old female presents with “intermittent squeezing chest pain”
HPI: 66-year-old female presents today with complaints of exertional mid-chest pain that has been occurring for the past 2 weeks. The patient describes the pain as a “squeezing feeling” that radiates to her left arm while she was cross country skiing in extreme cold weather. The patient states that the pain worsens in cold weather and is accompanied by dyspnea that is only alleviated with rest. The patient reports the chest pain to be moderate and reports a 6/10 on a pain scale when episodes occur. The patient reports a history of hypertension and hypercholesterolemia and reports a family history of heart disease. Upon physical examination, the patient is slightly overweight with a BMI of 25.5 but has a normal physical examination.
Medications: Hydrochlorothiazide (HCTZ) 12.5mg daily
Allergies: (medication, environmental, food) The patient denies any medication, environmental or food allergies
PMH: Hypertension and hypercholesterolemia. Denies other chronic
medical conditions.
LNMP/OB History (if indicated): The patient has no living children.
PSH: Denies any surgical or dental procedures.
Sexual History (if indicated): Deferred for this exam.
1/14/21 dws
Hospitalizations: None.
Health Maintenance: Reports going to primary care provider every 4 months to monitor her cholesterol and blood pressure.
Immunizations: Immunizations are up to date. Completed all childhood vaccines.
Family History: Paternal history of stroke. Maternal history of heart disease. Her sister had open heart surgery at age 58.

Substances (Tobacco, alcohol, illicit drugs, caffeine):The patient denies illicit drug use. The patient was a history smoking cigarettes (5 pack a year) and quit 15 years ago. Reports mild caffeine intake and reports
drinking 1-2 glasses of wine a day. Denies history of alcohol abuse or excessive alcohol consumption.
Home environment: The patient lives alone in a loft and reports a safe home environment.
Employment type: Currently a marketing executive with her own firm. Reports work hours and “long and demanding.”
Diet: Eats fast food and goes out to eat at restaurants regularly.
Sleep: Sleeps adequately and denies chest pain or dyspnea during sleep
Exercise: Active lifestyle. Performs aerobic exercises three times a week
Safety: Reports feeling safe at home. Denies history of physical or verbal abuse.

Objective Data

ROS: (Perform an appropriate ROS based on the C/C and HPI; documented in i-Human assignment; performed in final focused exam
General: Reports usual state of good health in addition to hypertension which is controlled with medication and exercise. Denies fever, chills, recent weight gain or loss, weakness, or fatigue. Eye contact is appropriate with clear speech. Reports the need to lose weight due to being slightly overweight, evidenced by a BMI of 25.5. Reports her weight has stated consistent.
Skin, Hair and Nails: Denies any recent lesions, rashes, changes in texture, or moles.
HEENT: Denies headaches, blurry vision, or vision changes. Denies ear problems or ear pain. Denies sinus problems or pain. Denies nasal congestion, cough, runny nose, sore throat, or sputum production. Denies
difficulty swallowing, pain in the jaw or neck.
NECK: Denies pain or stiffness of the neck. Denies swollen glands/lumps in neck.
Thorax and Lungs: Reports dyspnea with chest pain that is alleviated with rest. Reports worsening dyspnea and chest pain with exertion. Denies history of lung disease, allergies, or asthma. Denies wheezing, trouble catching her breath. Denies orthopnea, or paroxysmal nocturnal dyspnea.
Cardiovascular: Reports a history of mild hypertension that is managedwith medication (HCTZ 12.5mg daily) and hypercholesterolemia. Reports “squeezing” chest pain with dyspnea during exertion that is alleviated with rest. Reports the chest pain lasts a few minutes and has been occurring intermittently for the past two weeks, specifically during cross-country skiing. Reports pain is moderate and rates it a 6/10 on a pain scale. Reports chest pain is sometimes precipitated by exercise. The patient denies decreased exercise tolerance. Denies syncope, palpitations, dizziness, or pressure with or without exertion or with getting angry.
Peripheral Vascular: Denies upper and lower extremity edema, coldness,
leg cramps, skin ulcers or varicose veins.
Abdomen: Denies nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stools, bright red blood in bowel movements, bloating or early satiety.
Genitourinary: This exam was deferred.
Metabolic/Hematologic: Denies thyroid disease, heat/cold intolerance, excessive hunger, thirst, or history of diabetes. Denies history of anemia.
Psychiatric: Denies history of nervousness, depression, lack of interest, sadness, memory loss, mood changes, or hearing voices that are not there. Denies difficulty falling or staying asleep. Denies ideas or self-harm or suicidal ideation.
Musculoskeletal: Reports chest pain that radiates to left arm during exertion. Reports full range of motion in upper and lower extremities. Denies pain in other extremities. Denies any weakness or muscle wasting
of the upper or lower extremities. Denies difficulty walking or performing ADLs without assistance.
Neurologic: Denies history of stroke, syncope, seizures, or frequent/incapacitating headaches. Denies tremors, decreased alertness, or loss of sensation.
Vital Signs:
Temperature: 98.5 F, Pulse: 74, BP: 132/90, Respirations: 18
SpO2: 96%

Assessment

General: Slightly overweight middle-aged female, appears stated age, alert, and oriented x 4. No grimacing, respiratory or emotional distress noted. Skin, Hair and Nails: Skin is warm and dry with no lesions noted. Thickness and distribution pattern is typical for the patients’ gender and age. Capillary refill is less than 3 seconds in fingers and toes.
HEENT: The head is normocephalic and atraumatic. The scalp is nontender and has no visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions. There is no eyelid ptosis, erythema or swelling noted. Conjunctiva is pink with no discharge. Sclerae is anicteric. There is no edema, redness or tenderness noted on the orbital area. Both pupils are brisk and reactive to light. Normal appearing external ears. No deformities, or edema noted. No discharge noted. Normal appearing external auditory canals. Tympanic membrane translucent, non-injected, and pinkish gray in color. No scarring or discharge noted. Oropharynx not injected. Clear mucosa. Tonsils without exudate. Tongue pink in color and symmetrical. No swelling or ulcerations. Intact Gag reflex. No hoarseness noted. No unusual or foul swelling odor of the breath.
NECK: No lesions, or edema noted. No stiffness or pain noted. Full range of motion of the neck noted. Thyroid moves with swallowing. No pathologically enlarged lymph nodes noted in the cervical, supraclavicular, or axillary chains.
Thorax and Lungs: Anterior and posterior chest: Thorax is atraumatic, without deformity. Normal symmetrical respiratory effort with excursion. No costochondral point tenderness noted. No evident rib fractures. No vertebral tenderness. The anterior lung fields are resonant. The rest of the lung fields are resonant. All lungs fields are clear to auscultation. No wheezing, crackles or stridor noted. Symmetrical expansion and unlabored breathing are also noted.
Cardiovascular: Chest is symmetric, with no scars noted. No cardiac heaves or lifts. No edema noted. PMI is nondisplaced and noted at the midclavicular line, in fifth intercostal space. Normal Jugular venous
pressure. Normal heart rate and rhythm, normal S1 and S2 without murmur, click, gallop, or rub. No splitting of the heart sounds heard.
Peripheral Vascular: Extremities are warm and dry. Carotid pulses 2+ bilaterally. Radial pulses 2+ bilaterally. No peripheral edema, varicosities, or ulcerations noted.
Abdomen: Abdomen is soft to palpation. Nontender to upper quadrant and epigastric palpation. The patient’s symptoms cannot be produced with applied epigastric pressure. Bowel sounds normoactive in all 4 quadrants. No masses or bruits noted. Rectal examination was deferred.
Genitourinary: Deferred for this exam.
Psychiatric: Affect and speech is clear and appropriate. Calm emotional state. Concentration, activity level and attention are appropriate. No increased activity or agitation noted during examination.
Musculoskeletal: No asymmetry or deformity of the back noted. No tenderness or spasm noted of the paraspinal muscles. Steady gait with a normal posture noted. Test strength is 5/5 bilaterally. Full range of motion of the upper and lower extremities. No pain noted during ROM.
Neurologic: Alert, oriented to person, place, time, and situation. Pupils equal to light and accommodation. Facial movements are symmetrical. Head turning and shoulder shrug are intact to resistance. Tongue is midline with normal movements and no atrophy. Speech is fluent and clear. Deep tendon reflexes of the triceps, biceps, brachioradialis, and patella have a brisk response (2+).

Differential Diagnoses

Myocardial infarction: The patient reports with intermittent chest pain with exertion and dyspnea that radiates to the left arm for the past two weeks. The patient reports that when the chest pain occurs, the pain is moderate and reports a 6/10 on a pain scale. The recurrent chest pain may imply it is not an MI, since most MI’s present with constant chest pain but the possibility of an MI may still need to be ruled out.
Stable Angina: The patient reports with intermittent chest pain with exertion and dyspnea that radiates to the left arm for the past two weeks. The patient reports the chest pain lasts a few minutes and is alleviated with rest. Chest pain with exertion is a common finding with stable angina, especially when episodes last a few minutes.
Unstable Angina: The patient reports with intermittent chest pain with exertion and dyspnea that radiates to the left arm for the past two weeks. The patient reports the chest pain lasts a few minutes and is alleviated with rest. Unstable angina occurs without exertion, and during sleeping or resting. Since the patient reports alleviation with rest, it may not be unstable angina, but still needs to be ruled out.
Anxiety attack: The patient reports with intermittent chest pain with exertion and dyspnea that radiates to the left arm for the past two weeks. The patient reports the chest pain lasts a few minutes and is alleviated with rest. The patient states she has a high-stress career and enjoys cross country skiing to alleviate the stress of her job. However, anxiety attacks can occur during exertion, along with dyspnea and chest pain. It is unlikely that the patient has anxiety attacks that causes intermittent chest pain and dyspnea,
but it may also be ruled out.
Most Likely Diagnosis: Stable Angina evidenced by intermittent chest pain with exertion and dyspnea that radiates to the left arm that lasts a few minutes and is alleviated with rest. ECG was normal sinus rhythm. Troponin levels were within normal limits. Chest Xray was normal. The patient was also diagnosed with Coronary artery disease. Cholesterol was high, at 245mg/dl. LDL was moderately elevated at 140mg/dl and Triglycerides were also elevated at 175 mg/dl.

Plan

Health Promotion: (appropriate screening, disease prevention, and health promotion according to the patient’s age, gender, and identified risk factors…not diagnosis specific)
✓ Wellness Check- Continue to get lipid panel screening every 4 months to maintain and lower Cholesterol, Triglycerides, and LDL.
✓ Lose weight to lower cholesterol and blood pressure.
✓ Refrain or reduce intake of salty, fast foods, or restaurant meals. Try to cook or prepare healthy meals to lose weight and reduce sodium intake.
Screening
✓ Diabetes screening (women with HTN, CAD, overweight and the over age of 45 have increased risk for DM)
✓ Cancer screening- Cervical cancer screening (Pap smears every 3 years) Breast cancer (yearly mammogram), Immunizations
✓ Seasonal Flu vaccine
✓ Covid-19 vaccine

Complete Step-by-Step Guide to Writing the Florence Blackman iHuman Case Study

Completing the Florence Blackman iHuman case requires a systematic approach that mirrors real clinical practice. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, take a moment to review the doorway information and formulate your initial clinical approach.

Key Information to Note:

• 66-year-old female with “intermittent squeezing chest pain”
• 2-week duration of symptoms
• Consider immediate cardiac risk factors: age, gender, symptom description

Initial Clinical Mindset: Approach this case with cardiovascular conditions as your primary consideration. The age, gender, and symptom description immediately suggest potential coronary artery disease, making this a high-priority assessment requiring systematic evaluation.

Step 2: Conducting the History of Present Illness (HPI)

The HPI is crucial for establishing the foundation of your diagnosis. Use the OLDCARTS method systematically:

Onset: Ask about when the chest pain started and what she was doing

• Key points to elicit: Started 2 weeks ago during cross-country skiing in cold weather

Location: Determine the exact location and radiation pattern

• Target response: Mid-chest pain radiating to left arm

Duration: How long do episodes last

• Important detail: Episodes last 5-10 minutes, then resolve

Character: Detailed description of pain quality

• Critical descriptor: “Squeezing” sensation (classic for angina)

Aggravating factors: What makes it worse

• Essential findings: Cold weather, physical exertion/exercise

Relieving factors: What provides relief

• Key response: Rest consistently relieves symptoms

Timing/Treatment: Pattern and current treatments

• Important pattern: Predictable with exertion, initially helped by reducing activity intensity

Severity: Pain scale rating

• Typical response: 6-7/10 during episodes

Associated Symptoms:

• Ask specifically about: dyspnea on exertion, palpitations, nausea, diaphoresis
• Key finding: Shortness of breath accompanying chest pain

Step 3: Review of Systems (ROS)

Conduct a thorough but focused ROS, paying special attention to cardiovascular and related systems:

Cardiovascular:

• Chest pain/pressure (already covered in HPI)
• Palpitations, irregular heartbeats
• Exercise tolerance changes
• Syncope or near-syncope
• Orthopnea, paroxysmal nocturnal dyspnea

Respiratory:

• Shortness of breath patterns
• Cough, sputum production
• Wheezing

General:

• Fatigue levels, weight changes
• Night sweats, fevers

Gastrointestinal:

• Rule out GERD symptoms that could mimic cardiac pain
• Nausea and vomiting during episodes

Step 4: Past Medical History, Social History, and Family History

Past Medical History:

• Hypertension (currently managed with HCTZ)
• Hyperlipidemia
• Previous smoking history (5 pack-years, quit 15 years ago)
• Previous hospitalizations, surgeries

Family History:

• Critical finding: Strong family history of heart disease
• Maternal history of heart disease, sister with open heart surgery at age 58
• Paternal history of stroke

Social History:

• Occupation: Marketing executive with a demanding schedule
• Exercise habits: Regular aerobic exercise 3x/week
• Alcohol: 1-2 glasses of wine daily
• Tobacco: Former smoker (significant risk factor)
• Diet: Reports frequent fast food and restaurant meals

Step 5: Physical Examination Strategy

Perform a comprehensive cardiovascular-focused physical exam:

Vital Signs:

• Expected findings: Mild hypertension (132/90), normal other vitals
• Note: Patient should be pain-free at rest during exam

Cardiovascular Examination:

1. Inspection: Look for visible cardiac impulses, chest wall abnormalities
2. Palpation:
   • Point of Maximal Impulse (PMI) – should be non-displaced
   • Check for heaves, lifts, thrills
3. Auscultation:
   • All four cardiac areas
   • Listen for murmurs, gallops, rubs
   • Expected: Normal S1, S2 without abnormal sounds

Additional Key Exams:

• Jugular Venous Pressure (JVP): Assess for elevated pressure
• Carotid Arteries: Auscultate for bruits
• Lung Examination: Rule out heart failure signs
• Peripheral Pulses: Check radial, dorsalis pedis pulses
• Extremities: Look for edema, clubbing, cyanosis

Step 6: Developing Differential Diagnoses

Propose at least 3-4 appropriate differentials with rationales:

Primary Consideration: Stable Angina

• Supporting evidence: Predictable exertional pattern, relief with rest, classic radiation, risk factors

Secondary Considerations:

1. Unstable Angina
   • Rationale to exclude: Symptoms are predictable and consistently relieved by rest
2. Myocardial Infarction
   • Rationale to consider: New onset chest pain with cardiac risk factors
   • Rationale to exclude: Intermittent nature, consistent relief with rest
3. Atypical Chest Pain/Anxiety
   • Rationale: High-stress occupation could contribute
   • Less likely: Classic cardiac symptoms and significant risk factors

Step 7: Diagnostic Test Interpretation

Interpret provided test results to support your diagnosis:

Expected Key Findings:

• ECG: May show signs of ischemia during stress testing
• Stress Test: 2-mm ST depression in inferior and lateral leads
• Lipid Panel: Elevated cholesterol (245 mg/dl), LDL (140 mg/dl)
• Troponins: Normal (rules out acute MI)
• Chest X-ray: Normal cardiac silhouette

Clinical Correlation: Use test results to support a stable angina diagnosis and rule out acute coronary syndrome.

Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)

Primary Diagnosis: Stable Angina Pectoris secondary to Coronary Artery Disease

Justification:

• Classic exertional chest pain with a predictable pattern
• Relief with rest
• Radiation to left arm
• Multiple cardiac risk factors
• Stress test evidence of exercise-induced ischemia

MSAP Selection: Choose “Stable Angina” or “Coronary Artery Disease” as your Most Significant Active Problem, as this represents the primary condition requiring immediate management.

Step 9: Comprehensive Management Plan

Develop a multi-faceted treatment approach:

Immediate Management:

1. Risk Stratification: Duke Treadmill Score calculation
2. Consider cardiac catheterization based on stress test results

Pharmacological Interventions:

1. Antiplatelet Therapy: Aspirin 81mg daily
2. Beta-blocker: Metoprolol XR 25mg daily for rate control and anti-ischemic effect
3. Statin Therapy: Atorvastatin 40mg daily for cholesterol management
4. Continue HCTZ for blood pressure control

Lifestyle Modifications:

1. Dietary counseling: Reduce sodium, saturated fats
2. Exercise modification: Temporarily reduce intensity for 3 months
3. Stress management: Address work-related stress
4. Smoking cessation maintenance: Continue abstinence

Follow-up Plan:

• Return visit in 3-4 weeks to assess symptom improvement
• Monitor medication tolerance and effectiveness
• Consider a cardiology referral if symptoms persist

Step 10: Documentation and Submission Tips

Writing Your Summary:

• Create a concise 350-word summary explaining your clinical reasoning
• Include how you arrived at the problem list
• Cite specific assessment findings and lab correlations
• Use professional medical terminology

Key Documentation Elements:

1. Assessment Statement: Brief patient summary with key findings
2. Clinical Reasoning: Explain diagnostic thought process
3. Evidence Correlation: Link physical findings to test results
4. Management Rationale: Justify treatment choices

Final Submission Checklist:

• ✓ Complete history with OLDCARTS method
• ✓ Comprehensive cardiovascular physical exam
• ✓ Appropriate differential diagnoses with rationales
• ✓ Correct final diagnosis and MSAP
• ✓ Evidence-based management plan
• ✓ Professional documentation with proper citations

Florence Blackman Human Case Summary

Grading Criteria: The Florence Blackman iHuman case will evaluate you across several critical domains to ensure comprehensive cardiovascular assessment skills. Here’s what you need to focus on to maximize your score:

(1) History Taking (Major Points): You must ask targeted questions about chest pain characteristics to get full credit. Essential questions include: pain quality (squeezing/pressure), radiation pattern, triggers (exertion/cold), alleviating factors (rest), associated symptoms (dyspnea), and timing/duration. Don’t miss asking about: cardiac risk factors (smoking history, family history, hypertension, hyperlipidemia), medication compliance, and lifestyle factors. The rubric specifically rewards students who ask about pain severity using a 1-10 scale and relationship to physical activity.

(2) Physical Examination (High Weight): Focus your exam on cardiovascular and respiratory systems. Must-do components: vital signs (noting elevated BP), cardiac auscultation for murmurs/gallops, lung auscultation, jugular venous pressure assessment, and peripheral pulse examination. Pro tip: The rubric awards points for checking Point of Maximal Impulse (PMI) and examining carotid arteries – many students forget these key cardiac exam elements.

(3) Differential Diagnosis (Critical for Scoring): You need to propose at least 3 appropriate differentials with brief rationales. Expected differentials include: stable angina, unstable angina, myocardial infarction, and potentially anxiety/panic disorder. Scoring secret: The rubric rewards students who can distinguish between stable and unstable angina based on symptom patterns and triggers.

(4) Final Diagnosis & MSAP: You must correctly identify stable angina secondary to coronary artery disease as your Most Significant Active Problem (MSAP). Justification is key – cite the exertional nature, radiation pattern, and relief with rest as supporting evidence.

(5) Management Plan (Heavily Weighted): The rubric expects comprehensive management including: cardiac stress testing, medication optimization (beta-blockers, statins, aspirin), lifestyle modifications, and appropriate follow-up timing. High-scoring responses mention: Duke Treadmill Score interpretation and the need for possible cardiac catheterization based on stress test results.

(6) Patient Communication: Demonstrate empathy and clear explanation of the condition. Bonus points for: discussing lifestyle modifications specifically (diet changes, exercise modifications, stress management) and explaining warning signs that require immediate medical attention.

Example of a High-Scoring Clinical Summary

Here’s how a top-performing student might document this case:

Patient Summary – Florence Blackman

Situation: 66-year-old female presenting with 2-week history of exertional chest pain with classic anginal features.

Background: Significant cardiac risk factors including hypertension, hyperlipidemia, former tobacco use (5 pack-years), and strong family history of coronary disease. Currently on suboptimal antihypertensive therapy (HCTZ monotherapy with BP 132/90).

Assessment: Physical examination notable for stable vital signs with mild hypertension. Cardiac exam reveals normal heart sounds without murmurs. Stress testing demonstrated 2-mm ST depression in inferior and lateral leads, consistent with exercise-induced ischemia. Primary Diagnosis: Stable angina pectoris secondary to coronary artery disease.

Recommendation:

• Initiate dual antiplatelet therapy (ASA 81mg daily)
• Add beta-blocker (metoprolol XR 25mg daily) for rate control and anti-ischemic effect
• Optimize lipid management (atorvastatin 40mg daily)
• Consider cardiac catheterization based on Duke Treadmill Score of 10.5 (moderate-high risk)
• Lifestyle counseling: dietary modifications, temporary exercise limitation, smoking cessation maintenance
• Follow-up in 3-4 weeks to assess symptom improvement and medication tolerance

Patient Education Provided: Explained stable angina pathophysiology, importance of medication compliance, activity modification during treatment initiation, and clear instructions to seek immediate care for rest pain or prolonged symptoms exceeding 10 minutes.

Conclusion

By following this comprehensive approach to the Florence Blackman case, you’ll demonstrate the clinical reasoning skills that iHuman evaluates. Remember, success in cardiovascular cases requires systematic thinking: gather detailed history about pain characteristics, perform focused but thorough physical examination, consider appropriate differentials, and develop evidence-based management plans. The key is treating each iHuman simulation as you would a real patient encounter – be thorough, think critically, and always prioritize patient safety. With this guide, you’re well-prepared to excel in this challenging but rewarding case simulation.

Frequently Asked Questions

Q1: What is the correct diagnosis for Florence Blackman’s chest pain?

A: Florence Blackman‘s primary diagnosis is stable angina secondary to coronary artery disease. The key distinguishing features that point to stable angina include the predictable pattern of exertional chest pain that consistently resolves with rest, the classic “squeezing” quality with radiation to the left arm, and the reproducible triggers (cold weather and physical activity). Students often struggle between stable and unstable angina, but remember that stable angina has a predictable pattern and is relieved by rest, whereas unstable angina occurs at rest or with minimal exertion and represents a medical emergency.

Q2: What are the critical physical exam components I need to perform to score well?

A: Essential physical exam elements include measuring vital signs (noting elevated BP), assessing jugular venous pressure (JVP), auscultating carotid arteries, performing comprehensive cardiac auscultation including palpating for Point of Maximal Impulse (PMI), and conducting thorough lung examination. Many students miss points by skipping the JVP assessment and carotid artery examination, which are crucial for evaluating cardiovascular status. Don’t forget to examine the extremities for peripheral circulation and check for any signs of heart failure such as edema.

Q3: How do I pass the Florence Blackman case and meet the 70% requirement?

A: You must score a cumulative 70% on the iHuman assessments to successfully complete the required lab component. To achieve this score, focus on thorough history-taking using the OLDCARTS method for symptom analysis, complete all recommended physical exam components, propose appropriate differential diagnoses (including stable angina, unstable angina, and myocardial infarction), and develop a comprehensive management plan that includes both pharmacological interventions and lifestyle modifications. The key is being systematic and not rushing through any section.

Q4: What management interventions should I include in my treatment plan?

A: The comprehensive management plan should address both immediate stabilization and long-term cardiovascular risk reduction. Include cardiac stress testing to evaluate ischemia, optimize existing medications (consider upgrading from HCTZ monotherapy to combination therapy), initiate cardioprotective medications (aspirin, beta-blockers like metoprolol, and statins for cholesterol management), and provide lifestyle counseling regarding diet, exercise modification during treatment initiation, and stress management. Students often forget to address the need for follow-up care and patient education about warning signs that require immediate medical attention, which are important components for comprehensive care and can impact your overall score.