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Excerpt
HISTORY - A 21-year old NCAA Division I female basketball player presented with a complaint of severe substernal chest pain which began eighteen hours earlier. The pain was described as being sharp, continuous, worse in the supine position and during inspiration, and improved when sitting or standing. The pain radiated to the left anterior chest, neck, shoulders and back. She denied any fever but did complain of a sore throat. Review of symptoms was significant for shortness of breath of two months duration.
PHYSICAL EXAMINATION - Initial examination revealed a tall, thin, ill-appearing African American female. Her vitals demonstrated an oral temperature of 38 degrees Celsius, a blood pressure of 112/60, a pulse rate of 92/minute and a respiratory rate of 16/minute. Her height was 1.83 meters and weight was 70.3 kg. Examination of the head and neck demonstrated an erythematous posterior oropharynx, without tonsilar enlargement or exudate. There was no lymphadenopathy, carotid bruits or venous congestion. Cardiac auscultation revealed normal S1 and S2 heart sounds with a pericardial friction rub and a grade III diastolic decrescendo murmur. Auscultation of the lungs revealed no rales, rhonchi or wheezes. There was no hepatomegaly. The remainder of the physical examination was unremarkable.
