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SumawayCA

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: SUMAWAY, Felicidad Age/Sex: 83/F Address: 2943 Rd.3 BO. Obrero, Pandacan, Manila Date of Admission: March 28, 2008 Admitting Diagnosis: CAP, moderate risk IHD, lateral wall ischemia, AF with MVR, II-B HCVD, LVH r/o ACS Residents in charge: Drs. Gutierrez/Dimaandal/Areja Clerks in charge: Florentino/Ingles

Hospital No: 1621442

Clinical Abstract This is a case of an 83 year old female who came in due to dyspnea. History of Present Illness 1 week PTA, the patient had cough productive of whitish sputum accompanied with fever, undocumented relieved by Paracetamol. There was no difficulty of breathing, no chest pain, no colds. No consult was done, no other medications were taken. 4 days PTA, the cough persisted but the fever subsided. A few hours, persistence of symptoms prompted the consult. Past Medical History Previous admission December, 2007 – diagnosis: CAP, MR HCVD, CAD/IHD, LVH No hypertension, Diabetes Mellitus and Allergy No goiter, asthma and PTB Family History Denies heredofamilial disease Personal Social History Non-smoker Non-alcoholic beverage drinker Review of Systems

Gen: no weight loss , no anorexia, HEENT: no headache, no dizziness, no blurring of vision, no tinnitus, no epistaxis, no dysphagia, Respiratory: no cough, no colds, Cardiovascular: (+) occasional chest pain at exertion, no palpitations, no orthopnea, (+) easy fatigability GIT: no diarrhea, no vomiting GUT: no dysuria, no oliguria, no hematuria Endo: no polyuria, no polyphagia, no polydipsia Hema: no easy bruisability MSS: no myalgia, no arthralgia
Physical Examination

Gen: conscious, coherent, not in cardio-respiratory distress, afebrile BP: 150/100 CR: 84 RR: 31 Temp: 37°C HEENT: Anicteric sclera, pink palpebral conjunctivae, no cervical lymphadenopathy, no tonsillopharyngeal congestion, no neck vein engorgement C/L: symmetric chest expansion, no retractions, (+) tachypnea, (+) crackles on left basal lung th Heart: adynamic precordium, PMI at 6 ICS LMCL, irregular rate, irregular rhythm, no murmurs Abdomen: flat, normoactive bowel sounds, soft, no tenderness Ext: grossly normal, no cyanosis, no edema ASESSMENT: CAP, moderate risk CAD, lateral wall ischemia, AF with MVR, II-B HCVD, LVH Plan: For admission


								
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