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
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