Patient’s Profile

Name: MIC
Sex: Male
Age: 64years old
Religion: Roman Catholic
Civil Status: Married
Occupation: Carpenter
Income: P 6,000/ month
Nationality: Filipino
Date Admission: June 29, 2007
Time: 09:40pm
Chief Complaint: Epigastric Pain
Diagnosis: Acute myocardial infarction; Hypertensive
cardiovascular disease; ruled out PUD; diabetic nephropathy
Attending Physician: Dr. Siy

BASELINE VITAL SIGNS

Temperature: 36.6 C
Pulse Rate: 54 bpm
Respiratory rate: 18cpm
Blood Pressure: 130/100 mmHg
Height: 5’3’’
Weight: 55.5 kg

Health History

1. History of Present Illness

The patient has experienced chest pain with complaints of acute epigastric pain, growing
in character and on and off. The patient also anorexic and hypertensive (180/ 60 mm Hg).
Then, with the help of his family he went to the hospital for check-up, they thought that it
was just an ulcer, but the doctor had a diagnosis of Acute myocardial infarction;
 Hypertensive cardiovascular disease; ruled out PUD; diabetic nephropathy. Then due to
the severity of pain he was prompted for admission at Polymedic General Hospital.

2. Past Medical History

He has a hypertension in the year 1998 when he was still 55 years old. In 2006 he
experienced severe chest pain because of overwork and emotional stress. Also that same
year he was diagnosed of having Diabetes Nephropathy and Chronic Renal Insufficiency
and was admitted at Northern Mindanao Medical Center. During his admission last 2006,
MIC has been transfused with 5 bags of Packed Red Blood Cell and there were no reports
of allergic reaction. At that time, he was advised by the doctor to have his monthly check-
up for his health problems.

3. Family Medical History

According to his wife, there were no history of health problems from their family. Also
nobody aside from her husband has been admitted for chronic illness.

4. Social History
The patient said that he was an alcohol drinker during his adolescence and late adulthood
and confessed that he only drinks 2-6 glasses or more on occasional basis. And also he
has no history of cigarette smoking. Then his children also are non-smoker nor alcoholic
drinker, but they occasionally drink alcohol.

Course in the ward

Day 1
A Male Patient who's at 64years of age has a critical health problem. Upon assessment
last June 29, 2007 he was received with a Diagnosis of Acute Myocardial infarction;
Hypertensive Cardiovascular disease; ruled out PUD; diabetic nephropathy. The patient
was sitting on bed and complaint on pain of chest area. Instruct him to deep breathing
exercise everytime chest pain is recurring. Also the data about the patient's family and
personal health history were gathered.

Day 2
On the Next Day, Management & Intervention have been executed to the patient. He was
able to lessen the pain in chest area because of oxygen and also his vital signs were
 monitored for his blood pressure. Due to the medication prescribed by his assigned
physician it kept the patient in moderate, relax and rest comfortably in the bed. Patient
was observed for unexpected or abnormal assessment and no complaint was noted.

Discharge Planning/ Recommendations (METHODs)

Medication  Advised the patient to take the medicines exactly as

directed at regular basis.

Exercise  Advised the patient to have light exercise to strengthens

the heart and improves circulation. It’s good to lower
blood pressure Also it can increase the oxygen levels of
the body.

Treatment  The patient is provided with the ff:

a) Supplemental oxygen by nasal cannula
b) Cardiac Monitoring
c) Monitoring the Vital Signs (TEMP, PR, BP,
INTAKE/OUTPUT)
d) Therapeutic management to stabilize the patient’s
condition

Outpatient  Discuss to the patient the importance of follow up

checkup
 Upon discharging, out patient must have support and
guidance coming from his family and health care
providers specially the assigned physician related to
treatment of disease and education and counselling about
lifestyle medication.

Diet  Instruct the patient to eat less CHO foods and more in
fibers (fruits, vegetables and whole grains such as brown
rice&oatmeal). The patient is diabetic o that avoid to eat
sweets and added sugar like chocolates, soft drinks and
etc….
 Low in calorie, saturated fats and cholesterol. Also
limited intake of foods with high sodium.
 Recommendation
 Advised the patient to have followed up checkup
 Advised patient to monitor his vital signs always
 Encourage the patient to have a healthy lifestyle and exercise regularly even light
exercises
 Think always positive and be optimistic all the times to avoid stress / teach coping
mechanism for stress
 Teach patient the coping mechanism for recurring chest pain
 Encourage to eat healthy foods like fruits and vegetable; less in carbo, more in fiber ad
protein.