IDENTIFYING DATA

IDENTIFYING DATA

            The patient is a 47-year-old male, married, Filipino, Roman Catholic, from Sta. Mesa, admitted for the second time at a local hospital last December 24, 2013.

PATIENT PROFILE

The patient lives with his wife and two children in a two-storey concrete residence with adequate supply of electricity, water, and indoor plumbing. The residence is said to well-ventilated and is situated in a congested neighborhood. Community waste is collected daily. Patient has been employed as a cement factory worker for the past 20 years; he works 6x/week and is regularly exposed to dust. He wakes up at 4am and works from 7 am to 5 pm and sleeps at 9 pm. He is a non-alcoholic beverage drinker with a 4 pack year smoking history. His usual diet consists of 2 cups of rice paired with a viand ranging from meat, fish, and vegetables; patient is fond of meat and fatty food. Patient is fond of caffeinated drinks; patient consumes 5 cups of coffee per day. He has regular bowel movement, 1-2x daily, and is said to engage in mild forms of exercise such as walking. 

CHIEF COMPLAINT

            Chest pain of 2 hours duration

SOURCE AND RELIABILITY

            Informant was the patient and his wife, with good reliability

HISTORY OF PRESENT ILLNESS

2 hours PTA, previously well patient experienced sudden onset retrosternal chest pain while watching television, described as chest heaviness, 10/10, radiating to the left arm which was unremitting and persistent for 2 hours. Chest pain accompanied by shortness of breath, diaphoresis, and generalized weakness. Pain neither aggravated nor alleviated by change in position and recumbency. Rest and intake of Omeprazole failed to afford relief. Patient noted to be restless and had two episodes of vomiting previously ingested water. No symptoms of fever, abdominal pain, nape pain, syncope, previous chest pains, orthopnea, and dizziness noted. Persistence of symptoms prompted consult.  

PAST MEDICAL HISTORY

Patient was diagnosed with Gastroesophageal Reflux last December 2013 at Sta. Ana Hospital where he was prescribed Omeprazole 20 mg/cap 1 cap TID and Maalox 1 tablet BID

Previously admitted last April 2013 for 2 days at UERM due to hypokalemia; resolved

No history of previous operations and trauma

FAMILY HISTORY

            History of hypertension on maternal side

            No history of diabetes mellitus, asthma or tuberculosis

            No history of malignancy

REVIEW OF SYSTEMS

SYSTEMS DESCRIPTION

General

(-) night sweats, (-) fever,  (-) weight loss, (-) anorexia , (-) easy fatiguability Unremarkable

Skin

(-) pallor (-) rashes (-) itching  (-) changes in hair/nails 

(-) jaundice (-) change in color 

Unremarkable

Eyes (+) visual impairment  (-) tearing (-) pain (-) double vision (-) discharge (-) redness With symptoms of presbyopia for the past 3 years; on reading glasses

Ears (-) hearing loss (-) discharge (-) tinnitus Unremarkable

Nose, Throat, Mouth (-) nasal mucus discharge (-) nasal obstruction (-)   tooth ache (-) dental caries (-) gum bleeding (-) change in voice Unremarkable

Respiratory (-) hemoptysis (+) colds Recurrent colds due to frequent occupational exposure to dust

Cardiovascular (-) palpitation (-) syncope (-) chest pain  

Urinary (-) decrease frequency (-) nocturia (-) pain (-) bleeding (-) change in color Unremarkable

Gastrointestinal (-) constipation (-) frequency (-) bleeding (-) indigestion (-) loss of appetite Unremarkable

Musculoskeletal (-) joint pains  (-)  swelling (-)  joint stiffness (-) calf tenderness Unremarkable

Endocrine (-) heat/ cold intolerance (-) neck surgery (-) DM indicators Unremarkable

Extremities

(-) edema (-) cyanosis (-) clubbing (-) varicosities 

(-) claudication

Unremarkable

Genitourinary (-) discharge (-) pain Unremarkable

Hematopoetic (-) excessive bruising/bleeding (-) anemia Unremarkable

Nervous System (-) dizziness (-) fainting spells (-) headache (-) tremors, seizures Unremarkable

Endocrine System (-) heat intolerance (-) thyroid problems (-) neck surgery/ irradiation (-) DM indicators Unremarkable

Psychiatric (-) Mood swings (-) behavioral changes (-) anxiety (-) depression Unremarkable