General Data

FBS, 69-year old female, from Balangiga, E. Samar

Chief Complaint: severe epigastric pain

History of Present Illness

16 days PTA, patient experienced severe epigastric pain, 9/10 on pain scale,
characterized as steady, radiating to the back and chest. Associated with nausea. No vomiting,
no loose stools, no melena, no hematochezia. Patient sought consult at EVRMC and was
consequently admitted. Diagnosis was unrecalled but noted elevated amylase, SGPT and SGOT
in her laboratories. She was given unrecalled intravenous medications and was discharged
improved after 3 days. In the interim, no recurrence of epigastric pain noted and patient
recuperated unremarkably at home.
Hours PTA, epigastric pain recurred, still characterized as steady, burning, radiating to
the back and chest, 9/10 on pain scale. With nausea and difficulty breathing. No vomiting, no
loose stools. Patient was brought to a local hospital in Balangiga, E. Samar, and was initially
managed as GERD, to r/o ACS, given PNSS IVF at 30 gtts/min, Ranitidine 1amp IV stat, Aspirin
80mg 2tabs chewed and swallowed, and O2 inhalation at 3-4 lpm via nasal cannula. Persistence
of epigastric pain prompted referral to DWH. Hence, admitted.

Past Medical History

Hypertension, on Carvedilol 6.25mg ½ tab OD
Diabetes Mellitus Type 2, on Sitagliptin+Metformin 50/500mg 1tab BID
Dyslipidemia, on Rosuvastatin 10mg 1tab OD
Stroke without residuals (September 2017)
Limb Ischemia, Right Leg, s/p AKA (November 2017)
s/p Cardiopulmonary Arrest, t/c Myocarditis; Cardiac Arrhythmia (Atrial Fibrillation
currently Sinus)
FC IIIC; Uremic Encephalopathy secondary to Urosepsis (July 2018)
CAD, s/p Angioplasty (July 2018), on Trimetazidine 35mg 1tab BID, Clopidogrel 75mg
1tab OD

Family History
Hypertension, Diabetes - mother

Personal-Social History
Non-smoker
Non-alcoholic

Review of Systems
General: Anorexia. No weight loss. No fever.
Skin: No pruritus.
HEENT: No dizziness, no blurring of vision, no tinnitus, no hearing loss, no nasal
stuffiness, no sore throat, no hoarseness, no dysphagia
Neck: No stiffness, no pain
Respiratory: No cough, no hemoptysis
Cardiovascular: No palpitation, no orthopnea, no paroxysmal nocturnal dyspnea
Gastrointestinal: No vomiting, no loose stools, no constipation
Genitourinary: No dysuria, no hematuria, no urinary incontinence, no urinary frequency,
no anuria
Peripheral Vascular: No intermittent claudication, no leg cramps
Musculoskeletal: No joint pains, no stiffness, no backache
Neurologic: No mood changes, no attention nor speech deficit, no disorientation, no
disturbance in balance
Endocrine: No excessive sweating, no heat nor cold intolerance, no polydipsia, no
polyphagia, no polyuria

Physical Examination
Patient was examined awake, conscious, coherent, GCS 15, with the following vital signs:
BP 90/60 mmHg HR 92 bpm RR 20 cpm T 36.2 oC Pain Scale 9/10
Skin: Sallow, no active lesions, senile skin turgor.
Head: Normocephalic, atraumatic.
Eyes: Non-sunken eyeballs, pink palpebral conjunctivae, anicteric sclerae. Pupils equally round
and briskly reactive to light and accommodation.
Ears: No discharges, no tragal tenderness.
Nose: No discharges, midline nasal septum.
Mouth and throat: Moist pink lips, moist pink tongue and oral mucosae. Non-hypertrophic
tonsils, non-hyperemic pharynx.
Neck: No neck vein engorgement. Trachea at midline, thyroid gland not palpable, no
lymphadenopathy. Thyroid cartilage moves with deglutition.
Chest and Lungs: Symmetric chest expansion, confirmed chest excursion, unimpaired
tactile fremitus. No tenderness. Resonant on all lung fields.
Bronchovesicular breath sounds.
Heart: Adynamic precordium. PMI at 5th ICS LMCL. Regular rhythm, synchronous with pulse. No
murmur.
Abdomen: Flabby, no hematoma nor discoloration, soft, direct tenderness on epigastric region,
non-palpable liver and spleen, hypoactive bowel sounds.
Extremities: Full and equal pulses. No edema. Amputated right thigh.