PEREZ, EUNICE MARIE F.

2C MED

DR. REGALA

A.R. a 66 y/o male, born on March 28, 1945, is a retired seaman since 1995. He is a Filipino and his religion is Roman Catholic. He is married, has 2 children and currently living in Malate, Manila. Chief Complaint : Chest Pain History of Present Illness: The patient experienced Myocardial Infarction in 2005 with a grade of 10/10 for pain that lasted a few hours. Thus, he was admitted to a hospital in Bicol for 3 days. After his confinement, he was prescribed maintenance drugs that he stopped using after 3 months.

Last January, he again felt chest pain which lasted only 5 minutes that occurred every 4 days and was tolerable. This was relieved by rest and when lying on a lateral recumbent position. The patient sleeps with 2 pillows under his head. He didnt take any medication and no consultation was done at this time.

One day prior the admission, while the patient was walking towards his nephews school, he experienced chest pain which he described as heaviness in the substernal area. He graded the pain as 3-4/10 which persisted for 20-30 minutes. There was no cold or clammy feeling. He went to the nearby clinic and was given Nitroglycerine. After an hour, he was referred to Ospital ng Maynila. There, he was again given Nitroglycerine. No ECG or laboratory procedures were done. After his blood pressure lowered and his chest pain gone, he was sent home.

The next day, the patient went to UST-OPD for further check-up. He was asymptomatic but had a blood pressure of 190/90. ECG was requested and showed the previous infarct. He was then taken to the ICU for close check-up and stayed there for 2 days. Past Medical History: (+) Hypertension (since 1990, no medications) (-) Diabetes Mellitus (-) Pneumonia (-) Allergies (-) Asthma (-) Surgery Family History: Father: (-) HTN (died of beri-beri in 1950) Mother: (-) HTN (died of old age) Personal and Social History: (-) Smoking (-) Drugs Drinks half-bottle of alcohol occasionally Review of Systems: General: (-) weight loss, (-) anorexia, (-) weakness Skin: (-) itchiness, (-) color changes, (-) pigmentation, (-) rash Eyes: (-) blurring of vision, (-) redness, (-) pain, (-) lacrimation Nose: (-) colds, (-) discharge, (-) epistaxis, (-) obstruction Throat: (-) sorethroat, (-) tonsillitis Ear: (+) deafness in Right Ear, (-) ear discharge, (-) tinnitus Respiratory: (-) dyspnea, (-) cough, (-) shortness of breath, (-) sputum production, (-) hemoptysis Gastrointestinal: (-) diarrhea, (-) abdominal pain, (-) constipation, (-) melena, (-) nausea, (-) vomiting, (-) food intolerance Genitourinary: (+) frequency, (+) nocturia, (-) hematuria, (-) dysuria, (-) urethral discharge Musculoskeletal: (+) joint pain at times, (-) swelling, (-) wasting, (-) abnormal posture Endocrine: (-) polyuria, (-) polydypsia, (-) polyphagia, (-) heat and cold intolerance, (-) thyroid roblems

Physical Examination: Conscious, Coherent Bp 180/110, PR 108 bpm, RR 15cpm, Temperature 36.5C Warm moist skin, no rashes Pink palpebral conjunctiva Neck veins not distended Adynamic precordium Apex beat at 5th left ICS No heaves No lift No thrills No murmurs S1 louder than S2 at apex, S2 louder than S1 at base Peripheral pulses can be felt *P.E was done by the junior intern while we were interviewing the patient. The patients bp went high all of a sudden and we were asked to leave by his companion.