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General Data

This is the case of patient X, a 65 year old male, Filipino, married, Catholic, retired soldier born on
august 28, 1953 in Rosario, La Union, currently residing on Gibraltar Baguio City. Admitted in this
institution for the Second time on November 6, 2018 under the service of Dr. Manalo and Dr. Turqueza.
The informant is the patient with a 90% reliability

Chief Complaint:

Chest Pain

History of present illness

The patient is a known case of Chronic Kidney Disease Stage V on renal replacement therapy. 12
hours prior to admission, the patient underwent hemodialysis and decide to change the dialyzer that he
frequently uses to a new one. During the hemodialysis, he started to experience chills and cold tolerance,
not associated with fever, chest pain, palpitation and diaphoresis. The patient continued with the
procedure, completing the session which lasted for 4 hours

8 hours prior to admission, immediately after hemodialysis, he started to experience chest pain,
described as stabbing, 9/10 radiating to the right nape area. There was associated dyspnea, dizziness,
diaphoresis, easy fatigability, nausea and one episode of vomiting of previously ingested food and clear
watery fluid. There were no associated palpitation, headache, cough and fever. The hemodialysis nurses
examined the patient and he was found to be hypotensive at 80/50 and had a low SpO2, prompt them to
hook the patient to O2 at 2lpm via nasal cannula which relieved the desaturation. No other medications
taken. Persistence of symptoms prompted consult in this institution, and was subsequently admitted

Past medical history

Patient is known hypertensive since 2008 and is a known diabetic since 2013, with maintenance
medication of Amlodipine 10 mg OD. Maintenance for diabetes mellitus, which included insulin, was
stopped voluntarily by the patient as he claimed that his blood sugar has normalized. Patient is a known
case of chronic kidney disease stage V secondary to diabetic kidney disease since 2013, on renal
replacement therapy twice a week. The patient was admitted for myocardial infarction in 2015. No history
of cancer, asthma, pulmonary tuberculosis and allergies. No history of surgery. Other medications taken
include ferrous sulfate + Folic Acid supplement OD.

Family history

The patient has a family history of hypertension, diabetes mellitus and cardiac disease on the both
parental side. There is no familial history of asthma, cancer, cerebrovascular disease and liver disease and
kidney disease.

Social and Environmental history

The patient finished 2nd year college with the course of BS Agriculture, is a retired soldier and
currently lives in a house made of concrete with 3 other occupants. He is a previous smoker with 20 pack
years, stopped in 2013 and is a non-alcoholic drinker. Drinking water is from a refilling station and water
for domestic purposes comes from Baguio Water District. Proper garbage segregation is observed and
collected weekly by the city government.