Date and Time: June 03, 2014; 4:15 p.m.

Source: Patient
% Reliability: 100%
General Data:
N.R., 47 years old, female, Filipino, married, a Roman Catholic, works as a
supervisor of Mico Couture Group of Cos. Inc., currently residing in Guadalupe, Cebu,
born on May 17, 1967 in Cebu City is admitted at Cebu Doctors University Hospital on
May 30, 2014 for the second time.

Chief Complaint: Dyspnea with Chest Tightness

History of Present Illness:

Five days prior to admission, patient was apparently well until a sudden onset of
dyspnea occurred at rest. It was accompanied by nausea and pain on her right chest,
with a pain scale of 9/10, nonradiating, intensified during inspiration. No medications
taken, no relieving factors distinguished. She was then brought to Cebu Doctors
University Hospital Emergency Room where she was initially given Norgesic (35mg
Orphenadrine/ 450mg Paracetamol) for pain but no signs of relief was noted, hence,
given Tramadol 50mg/ml IM. Patient was partially relieved, now with a pain scale of
5/10. She underwent electrocardiogram and chest x-ray and was told to have normal
findings. She was sent home and was prescribed with Norgesic
(Orphenadrine/Paracetamol) 1 tab PO PRN for pain.

Patient had a 3 pillow orthopnea, causing sleep disturbances, bringing her to a

sitting position and leaning forward. Associated symptoms include fatigue and
restlessness. No reported fever, chills, cough, vomiting, night sweats, chest palpitations,
difficulty in urination nor change in bowel movements and no loss of appetite.

Three days prior to admission, despite her condition, patient returned to her
usual daily activities when she had an onset of fever. No temperature was taken and
self medicated with Rexidol (Paracetamol) 1 tablet every 6 hours, providing relief. On
and off episodes of dyspnea with accompanying chest pain persisted, which is
aggravated by walking and slightly relieved by sitting down and taking her prescribed
PRN medication. She then decided to seek consult with a Cardiologist. Patient went
through a Treadmill Stress Test as well as Two Dimensional Echocardiogram (2D Echo)
and was informed that the results showed no significant findings. No medication was
prescribed.

Few hours prior to admission, while in the middle of a business meeting, patient
suddenly felt dizzy, cant hardly breathe accompanied with chest discomfort, in a great
distress and was immediately rushed to the emergency room. Blood pressure taken
was 90/60 mmHg and a temperature of 40C.

Past Medical History:

Patient had measles, mumps and chickenpox during her childhood. She can no
longer recall her immunization status, but claims to have been vaccinated for influenza
every year for 13 years until 2011. No pneumococcal vaccination in the past. Patient is
non-hypertensive, with a usual blood pressure reading of 90/60 110/70 mmHg, non-
diabetic, no asthma and no history of any heart ailments.

Patient had her first hospital admission at St. Vincent Hospital in 1992 due to
appendicitis and appendectomy was done. Her second hospital admission was in Cebu
Doctors University Hospital in 2006 caused by gallstones and undergone Laparoscopic
Cholcystectomy. No prior accidents and injuries reported. Denied any psychiatric
disorders. Patient had her menarche at aged 16; subsequent menses described as
irregular with an interval of 2-3 months, moderate to heavy flow consuming 2-3 pads per
day for duration of 4 days and not associated with dysmenorrhea. No history of
contraceptive use. Patient has an Ob-score of G(2)T(2)P(0)A(0)L(2). She delivered via
NSVD in 1994 and in 1998 and both neonates were males. No maternal complication
known.

Personal & Social History:

Patient works as a supervisor in a garment company for two years and reported
to have been usually exposed to cigarette smoking of her co-workers. Her highest
educational attainment is graduating from high school. She loves to watch television
and sleep during her free time. She lives with her husband and their two children in a
house they own with running water and electricity. Patient started to drink alcoholic
beverages since she was 26 years old and seldom does, usually with 1 bottle of beer
per occasion. She does not smoke. Patient sleeps at least 6 hours a day and eats only
two meals a day (lunch and dinner), with no form of exercise and not taking any
supplements. No known drug and food allergy.

Patients spouse, 47 years old works as a maintenance man and said to have no
health issues. They have two male children with the age of 19 and 15 and both are
claimed to be in a good health.

Family History:

Patient is the youngest among 8 children (8/8). Her father died at the age of 90
due to fall secondary to his Alzheimers disease. He is a known hypertensive. Her
mother, 89 year old, have an Osteoporosis and is taking Caltrate Plus and Anlene milk
as prescribed by a physician. Three of his seven siblings are also know to be
hypertensive, medicating with Neobloc (Metoprolol) and have good compliance. No
other heredofamilial disease known.

PHYSICAL EXAMINATION (4th hospital day)

General Survey

Patient was conscious, alert, oriented to time, place and identity, coherent,

cooperative, ambulatory, physical and sexual appearance appropriate for age, no

involuntary movements, with signs of respiratory distress and with nasal cannula for

oxygen supplementation.

Vital signs

BP: 120/80 mmHg, right upper extremity, sitting

PR: 80 bpm, right radial, regular bounding force

RR: 32 breaths per cycle, rapid, shallow depth

Temp: 36.2 C, Right Axilla

Ht : 54

Wt: 50 kg

BMI: 18.5 (normal)

Skin

Skin is light-brown, warm, with good mobility and turgor. No Clubbing of nails and

cyanosis. Capillary refill time <2 sec. in both hands and toes. No pallor. No jaundice. No

skin lesions.

HEENT
 Head is normocephalic with no masses and lesions, face is symmetrical. Visual

acquity of J16 without the aid of corrective glasses and J1 using her reading glasses.

No masses on the eyelids and no scaling, no hair loss was noted on the eyebrows and

eyelashes. Cornea is smooth, moist and clear, the upper and lower palpebral

conjunctiva were pink and moist. Pupils are equally round (3mm); reactive to light and

accommodation. Full motility of the extraocular muscles was noted. (+) ROR, (-)

hemorrhage, (-) exudates seen on both eyes. No ear deformities or discharge,

Tympanic membrane was not bulging, appeared pearly-gray (+) cone of light.

Oral mucosa is pink and moist, gums are not swollen, tongue is pink and moist

and no lesions were noted. Dental carries was observed. No Tonsilar enlargement.

Neck is symmetrical, Trachea at midline, no visible enlargements or masses

were noted, can turn head in both sides without difficulty. Thyroid gland is non-nodular

and Lymph nodes were not palpable.

Chest and Lungs

Chest is symmetrical upon inspection, no deformities, no prominences over the

precordium. Patient is tachypneic with prominent sternocleidomastoid muscle during

respiration. No intercostal retractions. Unequal chest expansion and diminished tactile

fremitus noted at the base of the lungs. Dullness noted on right lower lobe; crackles

heard through the lower lung fields; diminished breath sounds at the right lower lobe.

Cardiovascular System
 The Jugular venous pulse is 3 cm above the sternal angle.The point of maximal

impulse is 7cm lateral to the midsternal line in the 5th ICS with a diameter of

approximately 2 cm. No thrills and lifts were noted; and cardiac borders were distinct;

Distinct S1 and S2; No murmurs noted.

Abdomen

Patients abdomen is slightly protuberant in supine position, it is symmetrical with

visible scars and striae. Normoactive bowel sounds at 10 bowel sounds per minute;

Tympanytic on percussion. Liver span of 7 cm along the Right midclavicular line and

about 4 cm along the midsternal line. No pain upon light and deep palpation on all

quadrants.

Extremities

No muscle atrophy, redness, edema, varicosities, cyanosis were noted. No pallor.

CRT <2 sec in fingers and toes. No skin discoloration.

Neurologic Examination

Mental Status:

Patient is awake, cooperative, oriented to time, place and person, clean, properly

clothed, appropriate facial expressions, able to speak well, articulates words properly

and no slurred speech.

Cranial Nerves

CN I : Patient is able to identify odor of alcohol on each nostril

CN II : Visual Acquity of J16 without glasses and J1 with corrective glasses

CN III, IV, VI : (+) direct and consensual pupillary light reaction, full extraocular

motility

CN V : Motor: patient can clench teeth; Sensory: (+) Corneal light reflex (V & VII)

CN VII : symmetrical face and appropriate facial expression; intact taste

CN VIII : can hear loud and spoken words on both ears

CN IX, X : No hoarseness of voice, (+) gag reflex , soft palate rises equally

CN XI : able to shrug shoulders against resistance

CN XII : tongue is symmetrical and at midline ; no atropthy

Motor
5/5 in the upper extremities and 5/5 in the lower extremities, patient is able to move
against resistance
Upper Extremities 5/5
Lower Extremities 5/5

Sensory
Patients sensation to pain, temperature, light touch and proprioception are intact.

Reflexes (+2)

Coordination
Patient is able to perform finger-to-nose test and alternating movements slowly
accompanied by tremors. No ataxia; intact position sense