TAMALE TEACHING HOSPITAL
P.O Box TL 16 Tamale ,Ghana
Tel: 03720-22454 Fax:03720-22458 Email: info.tamaleteachinghospital@gmail.com
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(ame of &atient: M). Thomas Ennin '*: +0,+0,+-43 M% (o.: 2405.,+3 ate of )epo)t: +0,04,20+3
HISTORY OF PRESENT ILLNESS: The patient is a 7+-/ea)-ol0 gentleman p)esente0 th)o1gh the eme)genc/ )oom on 02,+2,20+3 at 4:+5pm 2ith the 3/mptoms of sho)tness of 4)eath5 eas/ fatiga4ilit/5 an0 0i66iness. Main complaint 2as chest pain. !nitial 4loo0 test in the eme)genc/ )oom sho2e0 ele7ate0 *(& s1ggesti7e of congesti7e hea)t fail1)e. 8i7en histo)/ an0 his m1ltiple )is9 facto)s an0 2o)91p )ecentl/5 2hich has 4een as mentione0 4elo25 the patient 2as a0mitte0 fo) f1)the) e7al1ation. !nci0entall/5 his x-)a/ sho2e0 ca)0iomegal/ an0 pne1monia. CORONARY RISK FACTORS: :isto)/ of h/pe)tension5 no histo)/ of 0ia4etes mellit1s5 acti7e smo9e)5 choleste)ol ele7ate05 ;1estiona4le histo)/ of co)ona)/ a)te)/ 0isease5 an0 famil/ histo)/ is positi7e. FAMILY HISTORY: &ositi7e fo) co)ona)/ a)te)/ 0isease5 no famil/ histo)/ of ia4etes Mellit1s PAST SURGICAL HISTORY: The patient 0enies an/ ma<o) s1)ge)ies. MEDICATIONS: #spi)in5 "o1ma0in a0<1ste0 0ose5 0igoxin5 isoso)4i0e mononit)ate +20 mg 0ail/5 $asix5 potassi1m s1pplementation5 gemfi4)o6il .00 mg 4.i.0.5 an0 metop)olol +00 mg 4.i.0. ALLERGIES: (one )epo)te0. PERSONAL HISTORY: Ma))ie05 non-smo9e) 50oes cons1me alcohol. (o histo)/ of )ec)eational 0)1g 1se. PAST MEDICAL HISTORY: &atient is a 9no2n :/pe)tensi7e fo) +5 /ea)s no25 h/pe)lipi0emia5 co)ona)/ a)te)/ 0isease5 ca)0iom/opath/5 "'& 5 an0 p)esentation as a4o7e. The patient is on anticoag1lation on "o1ma0in5 the patient 0oes not )ecall the )eason. REVIEW OF SYSTEMS: "'(3T!T=T!'(#$: >ea9ness5 fatig1e5 an0 ti)e0ness. :EE(T: (o histo)/ of 4l1))/ 7ision an0 hea)ing impai)e0. (o gla1coma. +
TAMALE TEACHING HOSPITAL
"#% !'?#3"=$#%: 3ho)tness of 4)eath5 congesti7e hea)t fail1)e5 an0 a))h/thmia. &)io) histo)/ of chest pain. %E3&!%#T'%@: *)onchitis an0 pne1monia 8#3T%'!(TE3T!(#$: (o na1sea5 7omiting5 hematemesis5 melena5 o) a40ominal pain. =%'$'8!"#$: (o f)e;1enc/ o) 1)genc/. M=3"=$'3AE$ET#$: (o a)th)itis o) m1scle 2ea9ness. 3A!(: (on-significant. (E=%'$'8!"#$: (o T!#. (o "?# o) sei61)e 0iso)0e). E( '"%!(E: (on-significant. :EM#T'$'8!"#$: (on-significant. &3@":'$'8!"#$: #nxiet/. (o 0ep)ession. PHYSICAL EXAMINATION: ?!T#$ 3!8(3: &1lse of .05 4loo0 p)ess1)e of +50,80mm:g5 afe4)ile5 an0 )espi)ato)/ )ate +. pe) min1te. :EE(T: #t)a1matic an0 no)mocephalic. (E"A: 31pple. (ec9 7eins flat. $=(83: #i) ent)/ 4ilate)all/ 0ec)ease0 in the 4asila) a)eas 2ith scatte)e0 )ales5 especiall/ )ight si0e g)eate) than left l1ng. :E#%T: &M! 0isplace0. 3+ an0 325 )eg1la). 3/stolic m1)m1). #* 'ME(: 3oft an0 nonten0e)5 no o)ganomegal/ note0. EBT%EM!T!E3: T)ace e0ema of the an9le. &1lses a)e fee4l/ palpa4le. "l144ing pl1s. (o c/anosis. "(3: 8)ossl/ intact. M=3"=$'3AE$ET#$: #)th)itic changes. &3@":'$'8!"#$: (o)mal affect. LABORATORY AND DIAGNOSTIC DATA: EA8 sho2s sin1s 4)a0/ca)0ia5 int)a7ent)ic1la) con01ction 0efect. (onspecific 3T-T changes. $a4o)ato)ies note0 2ith :C: +0,32 an0 2hite co1nt of 7. !(% +.8. *=( an0 c)eatinine 2ithin no)mal limits. "a)0iac en6/me p)ofile fi)st set 0.045 *(& of +05000. (1clea) m/oca)0ial pe)f1sion scan 2ith a0enosine in the office 0one sho2e0 e<ection f)action of 3-D 2ith infe)io) )e7e)si4le 0efect. IMPRESSION: The patient is a 7+-/ea)-ol0 gentleman a0mitte0 fo): +. &ne1monia5 chest x-)a/ confi)ms the same 2ith sho)tness of 4)eath. 2. !schemic ca)0iom/opath/ 2ith a4no)mal st)ess test5 infe)io) 0efect5 e<ection f)action 3-D 2ith ele7ate0 *(&5 possi4l/ secon0a)/ to 1n0e)l/ing infection 7e)s1s 0ecompensate0 congesti7e hea)t fail1)e. 3. :/pe)tension5 an0 h/pe)lipi0emia.
TAMALE TEACHING HOSPITAL
He was Hosp !a" #e$ %&o' ()*+)*)(+, a-$ was $ s./a&0e$ o- )1*()*)(+23 He s .4&&e-!"5 % ! !o &es4'e / s -o&'a" a.! 6 ! es3
