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GROUP 2

Members:
RHEA ANGELIE ISLA AHILDEV, DEVADHAS PREMALATHA
MARAH KRYZZIA PURIFICACION RUSHNOL JADE TUPAC
CASEY JON VEA

HISTORY

NAME: AGE: SEX: CIVIL STATUS:


Mrs. L.D. 53 FEMALE MARRIED
ADDRESS:
ILAGAN, ISABELA
BIRTHDAY: RELIGION: OCCUPATION:
11/23/1964 ROMAN CATHOLIC FARMER
DATE/TIME OF ADMISSION: February 8, 2018 11AM
ADMITTING DIAGNOSIS

CHIEF COMPLAINT: NAUSEA, COUGH, CHEST PAIN

HISTORY OF PRESENT ILLNESS:


In 2011, while doing her work in their farm, Mrs. L.D experienced chest pain
characterized as 6/10, non-radiating and relieved by rest. When the pain subsided, she
continued doing her work. She said that the pain on her chest was recurring from time
to time but ignored it thinking it was just fatigue that she was experiencing.
In 2014, she had the same episode of chest pain and described it as more
severe with notable cough, shortness of breath and dyspnea. She also noted that from
the first time she experienced her symptoms, she experienced easy fatigability from her
usual farm work.
February 3, 2018, 5 days prior to admission, patient L.D. was doing her usual
work in their farm when she experienced bouts of coughing accompanied by chest pain
which she described as a squeezing sensation on her chest area radiating from her
chest to her upper abdomen. She also said she was nauseous. She said that when she
tried to rest, the pain still persisted. This prompted her family to rush her to their nearest
hospital before she was transferred to CVMC where she was admitted.
PAST MEDICAL HISTORY:
In 2014, the patient said that while she was working in their farm she
experienced an episode of chest pain accompanied by nausea, cough, shortness of
breath and dyspnea. This episode prompted her family to bring her to the nearest
hospital where she was admitted. She was diagnosed with pneumonia and was
discharged when she felt better.
Even though she’s taking aspirin for her chest pain as advised by her doctor, she
said that she was experiencing the pain more frequently the past couple of years and
when she had the same episode last February 3, which she described as more painful
than the previous attacks, she was rushed to their local hospital and was admitted.
The patient has no history of surgery, medication and any psychiatric illnesses.
All her children were born thru natural delivery.

FAMILY HISTORY:
Her parents died due to old age. All of her 8 siblings are alive and well. No family
history of diabetes, tuberculosis, kidney disease, anemia, epilepsy or mental illness.

PERSONAL AND SOCIAL HISTORY:


Born and raised in Ilagan, Isabela. She is married and has 5 children. She works as a
farmer. The patient does not smoke and drink alcohol. The patient’s diet is usually
vegetables with anchovies or fish paste and for breakfast coffee and bread.

REVIEW OF SYSTEMS:
GENERAL
SKIN
HEAD,EYES,EARS,
NOSE,THROAT
NECK
RESPIRATORY
HEART
GI
GU
MUSCULOSKELETAL

PHYSICAL EXAM
GENERAL:
BP: 110/90
HR: 86 bpm
T: 35.8 C
RR: 36 bpm
O2 Sat: 98%
SKIN
HEAD,EYES,EARS,
NOSE,THROAT
NECK
RESPIRATORY
HEART
GI
GU
MUSCULOSKELETAL
NEUROLOGIC

IMPRESSION: