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Patients Profile

MP
64 years old, female, married
Filipino, Roman Catholic
Housewife
Residing in Tinago, Cebu City
Admitted for the 1st time at VCMC
CC: Chest Pain

Past Medical History

Known hypertensive for 30 years


Highest BP: 200/120 mmHg; usual BP: 180/100
mmHg
Amlodipine 5mg/tab 1 tab OD and Losartan
50mg/tab 1 tab OD with good compliance

Known diabetic for 1 year


Highest blood sugar: 300mg/dl; usual blood
sugar 150-180mg/dl
Metformin 500mg/tab 1 tab TID

Past Medical History


Non-asthmatic
Non-diabetic
No known food and drug allergies
Previous hospitalization:
March 2016
Baking Medical Center
UTI
5 days; discharged improved

Personal & Social History


Non- smoker
Non- alcoholic beverage drinker
(-) history of illicit drug use
Diet: fatty, salty, sweet
House wife
Does not exercise
Usual activities: household chores

Family History
Hypertension: paternal
Diabetes Mellitus Type 2: maternal

History of Present Illness


Over the past 10 months
Left sided chest discomfort
Non radiating
After doing household chores
Recurrent episodes
Spontaneous resolution after periods of
rest

History of Present Illness


8 hours PTA

recurrence of left sided chest pain


squeezing in quality
radiation to the upper back
PS 8/10
Nausea, diaphoresis, weakness

History of Present Illness


8 hours PTA
Nifedipine 5mg/tab 1 tab taken with no
relief
Condition was tolerated

History of Present Illness


4 hours PTA
Persistence of chest pain with PS 10/10
No spontaneous resolution noted

Consult done at South General Hospital


ECG taken
Advised for ICU admission
Transfer to VCMC

Physical Examination
On admission, patient was conscious, coherent,
afebrile, not in respiratory distress & with the
following vital signs:
BP: RR: 20 cpm
HR: 72 bpm T: 36C/axilla
PS: 5/10 Ht: 160cm
Wt: 66kg

BMI: 25.78 kg/m2

O2 sat: 97%

Physical Examination
Skin: warm, good turgor, no lesions
HEENT: anicteric sclerae, pinkish palpebral
conjunctivae, no nasoaural discharges, no
tonsillopharyngeal congestion
Neck: supple, trachea at midline, no cervical
lymphadenopathy, no neck vein engorgement,
thyroid gland not enlarged

Physical Examination
C/L: equal chest expansion, equal tactile
fremitus, resonance on both lung fields,
clear breath sounds, no rales, no wheezes
CVS: adynamic precordium, PMI at the 5th
LICS MCL 2cm, distinct S1 and S2, normal
rate, regular rhythm, no audible murmurs

Physical Examination
Abdomen: flabby, normoactive bowel sounds, generally
tympanitic except at area of liver dullness, no palpable
masses, no organomegaly, no tenderness
GUT: no costovertebral angle tenderness, bilaterally
Extremities: warm, strong and equal peripheral pulses,
pinkish nailbeds, CRT of < 2 seconds, no peripheral
edema

Physical Examination
Abdomen: flabby, normoactive bowel sounds, generally
tympanitic except at area of liver dullness, no palpable
masses, no organomegaly, no tenderness
GUT: no costovertebral angle tenderness, bilaterally
Extremities: warm, strong and equal peripheral pulses,
pinkish nailbeds, CRT of < 2 seconds, no peripheral
edema

Physical Examination
CN7: good facial expression, no facial
asymmetry
CN8: able to hear spoken words at 2 feet
distance
CN9, 10: (+) gag reflex
CN11: able to shrug shoulders against
resistance
CN12: tongue midline at rest and upon

Physical Examination
Cerebellar: well-coordinated movements by
rapid alternating hand test, (+) finger to nose
test, heel to shin test
Motor: good muscle tone, no atrophy
5/5 5/5
5/5 5/5
Sensory: intact pain and touch sensation
Reflexes: +2 DTRs

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