GROUP 2

Members:
RHEA ANGELIE ISLA AHILDEV, DEVADHAS PREMALATHA
MARAH KRYZZIA PURIFICACION RUSHNOL JADE TUPAC
CASEY JON VEA

HISTORY

NAME: AGE: SEX: CIVIL STATUS:

Mrs. L.D. 53 FEMALE MARRIED
ADDRESS:
ILAGAN, ISABELA
BIRTHDAY: RELIGION: OCCUPATION:
11/23/1964 ROMAN CATHOLIC FARMER
DATE/TIME OF ADMISSION: February 8, 2018 11AM
ADMITTING DIAGNOSIS

CHIEF COMPLAINT: CHEST PAIN, NAUSEA

HISTORY OF PRESENT ILLNESS:

In 2011, while doing her work in their farm, The patient experienced chest pain
characterized as 6/10, non-radiating and relieved by rest. When the pain subsided, she
continued doing her work. She said that the pain on her chest was recurring from time
to time but ignored it thinking it was just fatigue that she was experiencing. She didn’t
seek any medical intervention.

In 2014, she had the same episode of chest pain and described it as more
severe with shortness of breath and dyspnea. She also noted that from the first time she
experienced her symptoms, she experienced easy fatigability from her usual farm work.

February 3, 2018, 5 days prior to admission, patient L.D. was doing her usual
work in their farm when she experienced bouts of dizziness and easy fatigability.

February 8, 2018, on the day of the admission, the patient was watching an
action film when she experience dizziness, dyspnoea accompanied by chest pain which
she described as a squeezing sensation on her chest area radiating from her chest to
her neck and to her back. She also said she was nauseous. She said that when she
tried to rest, the pain still persisted. This prompted her family to rush her to their nearest
provincial hospital and the attending physician took her blood pressure and was
recorded 160/100mmhg. She was advised to rest and was referred to CVMC for further
treatment. Upon arrival at CMVC, her vital signs was monitored and was given oxygen
therapy hence was admitted.
PAST MEDICAL HISTORY:
In 2014, the patient said that while she was working in their farm she
experienced an episode of chest pain accompanied by nausea, cough, shortness of
breath and dyspnea. This episode prompted her family to bring her to the nearest
hospital where she was admitted. She was diagnosed with pneumonia and was
discharged when she felt better.
Even though she’s taking aspirin for her chest pain as advised by her doctor, she
said that she was experiencing the pain more frequently the past couple of years. The
patient has no history of surgery, medication and any psychiatric illnesses. All her
children were born thru natural delivery.

FAMILY HISTORY:
Her parents died due to old age. All of her 8 siblings are alive and well. With a
family history of diabetes, hypertension and cardiovascular disease. No family history of
tuberculosis, kidney disease, anaemia, epilepsy or mental illness.

PERSONAL AND SOCIAL HISTORY:

Born and raised in Ilagan, Isabela. She is married and has 5 children. She works as a
farmer. The patient does not smoke and drink alcohol. The patient’s diet is usually high
in fat with anchovies or fish paste and for breakfast coffee and bread.

REVIEW OF SYSTEMS:
GENERAL (+) dizziness, (+) lightheadedness
SKIN
HEAD,EYES,EARS,
NOSE,THROAT
NECK
RESPIRATORY (+) dyspnea

HEART (+) chest pain

GI
GU
MUSCULOSKELETAL

PHYSICAL EXAM
GENERAL:
BP: 160/1000
HR: 96 bpm
T: 35.8 C
RR: 23bpm
O2 Sat: 98%
 SKIN Warm and dry skin with large amount of fat deposit. No
lesions.

HEAD,EYES,EARS,
NOSE,THROAT
NECK
RESPIRATORY Clear, no presence of crackles or wheezes

HEART Soft blowing systolic murmur from the 6th ICS to the axillary
line
GI
GU
MUSCULOSKELETAL No tenderness and distention
NEUROLOGIC Warm and without edema

IMPRESSION: ACUTE CORONARY SYNDROME T/C AMI