"Villestas_ Juanito_Clinical Abstract"
OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: VILLESTAS, JUANITO Age/Sex: 47/m Address: 163-C Lusito St., Sampaloc, Manila Date of admission: July 18,2007 Admitting Diagnosis: NSTEMI KI CAD, HCVD, LVH, NSR, E Residents in charge: Drs. Magbiray /Gonzales /Filio /Indon Clerk-in-Charge: Ocampo/Reloj/Rosarito Hospital #: 1711138 CLINICAL ABSTRACT This is a case of a 47 year old male who came in due to chest pain History of Present Illness Patient is a previous diagnosed case of CAD, HCVD, previously admitted 3 times in Ospital ng Sampaloc with poor compliance to Metoprolol and ISMN. On prn ISDN and Nifedipine. Patient was apparently well until 3 hours prior to consultation around 3pm, he experienced sudden onset of chest, after eating while he was resting. It was graded as 7/10 in severity, non-radiating, squeezing in character. No dyspnea, no dizziness, no numbness of left upper extremity, no diaphoresis. Self-medicated with ISDN 5mg SL 1 tab which afforded temporary relief of chest pain. 30 mins PTC, still with chest pain 7/10 in severity, squeezing non-radiating. No dyspnea. Took ISDN5mg SL which did not provide relief hence consult in this institution, hence admission. Past Medical History 2000, 2004, 2005 – admitted in OsSam due to chest pain, diagnosed with CAD, HCVD. Diagnosed with HPN for 7 years. HBP 180/120, UBP 130/90. no allergy no operation GSW – occipital area – claimed to have retained Family History (+) HPN – paternal side (+) DM – mother and sibling Personal and Social History Smoker of 11 pack years Occasional alcoholic beverage drinker 1-2x/week x 20 years Review of Systems N/A Physical Examination: General: Conscious, coherent, not in distress Vital Signs: BP:110/80 HR: 110 RR: 18 Temp: 36.8 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, no lagging, no retraction, no crackles HEART: adynamic precordium, PMI 6th ICS AAL , no murmur, tachycardic, regular rhythm ABDOMEN: globular, normoactive bowel sound, soft, non-tender, no mass EXTREMITIES: grossly normal, no cyanosis, no edema, full equal pulses. Assessment: NSTEMI KI CAD, HCVD, LVH, NSR, E PLAN: For admission