FEU-DR.

NICANOR REYES MEDICAL FOUNDATION

MEDICAL CENTER
Regalado Ave., Corner Dahlia Street, West Fairview Quezon City 1118
Telephone Number: 427-02-13

DEPARTMENT OF MEDICINE
CLINICAL HISTORY

GENERAL DATA:

GD, 48-year-old male, single, Filipino, Roman Catholic, born in Manila on November 18, 1972,
currently residing at Fairview, Quezon City admitted for the 1st time at FEU-NRMF Medical Center.

CHIEF COMPLAINT: Palpitations

HISTORY OF PRESENT ILLNESS:

3 hours prior to consult, patient experienced easy fatigability while doing his usual jogging routine.
It was associated with dizziness and feeling of light headedness and was partially relieved by rest. 1 hour
prior to consult, there was recurrence of the palpitations even at rest with associated left arm heaviness
and shortness of breath. There was no diaphoresis, abdominal pain, nor loss of consciousness noted. No
medications were taken. Patient then immediately went to the ER and was subsequently admitted.

PAST MEDICAL HISTORY:

 Hypertensive x 10 years.
o Usual BP: 140/90. Highest BP: 180/120.
o Amlodipine 10mg/tab, 1 tablet once daily (non-compliant)
 Non – diabetic
 No history of bronchial asthma, pulmonary tuberculosis
 No thyroid, liver, kidney diseases
 No known allergies
 No history of myocardial infarction nor cerebrovascular disease
 No previous surgeries
 No known history of cardiac dysrhythmia

FAMILY HISTORY:

 Father: apparently well

 Mother: apparently well
 5 siblings apparently well
 No other herofamilial diseases such as bronchial asthma, type 2 DM, blood dyscrasia nor
malignancy

PERSONAL AND SOCIAL HISTORY

Patient is single, a college graduate who works as an accountant. He lives with his parents and 5 siblings
in a well-lit, well ventilated 2-storey house. He gets 6 to 7 hours of sleep, prefers to eat fried food and
consumes 2-3 cups of coffee per day. He jogs 2-3 times a week. He is an occasional alcoholic beverage
drinker and a 10 pack year smoker. Denies history of sexually transmitted diseases nor illicit drug use.

REVIEW OF SYSTEMS
Constitutional: (-) weight loss/gain, (-) fever
Skin: (-) excessive sweating, (-) jaundice, (-) cyanosis
Eyes: (-) pain, (-) blurring of vision, (-) excessive lacrimation, (-) photophobia
Ears: (-) pain, (-) deafness, (-) tinnitus, (-) discharge
Nose and Sinuses: (-) change in smell, (-) epistaxis, (-) nasal obstruction, (-) pain around paranasal
sinuses Mouth and Throat: (-) Toothache, (-) Gum bleeding, (-) disturbances in taste, (-) sore throat,
(-) hoarseness Neck: (-) limitation of movement, (-) pain
Respiratory System: (-) hemoptysis, (-) shortness of breath, (-) orthopnea
Cardiovascular System: (-) chest pain, (-) orthopnea, (-) paroxysmal nocturnal
(+) dyspnea (+) palpitations
Gastrointestinal System: (-) dysphagia, (-) diarrhea, (-) constipation, (-)
hematochezia Genitourinary System: (-) urgency, (-) hesitancy, (-) hematuria,
(-) incontinence
Extremities: (-) swelling of joints, (-) limitation of movement (-) Edema
Nervous System: (-) paralysis, (-) speech disorder, (-) nystagmus, no lateralization on
Weber’s test
Hematopoietic System: (-) bleeding tendencies, (-) pallor, (-) easy bruising
Endocrine System: (-) intolerance to cold, (-) polyuria, (-) polydipsia

PHYSICAL EXAMINATION

General Survey: Patient is conscious, coherent, oriented to time, place, person; in cardiorespiratory
distress, with the following vital signs:

BP: 150/90 mmHg CR: 122 bpm RR: 22 cpm Temperature: 36.8 °C

Skin: Color is pink, warm, moist, with good turgor. Hair is thin and equally distributed. Nail beds and
plates were smooth and pink.

Head: Hair is thick, black, evenly distributed, no masses or tenderness; temporal arteries are not visible
but equally palpable.

Eyes: Eyebrows are black, thin, evenly distributed, no erythema and no lesions noted; palpebral fissures
symmetrical; eyelashes are thin, with outward direction of growth, no matting, pink palpebral conjunctivae,
anicteric sclerae, transparent cornea, lens are clear; iris are black with regular contours, pupils are 2-3
mm equally reactive to light and accommodation.

Ears: Auricles are symmetrical and non-tender; auditory canals are patent, no discharge; tympanic
membrane is pearly white, with visible cone of light.

Nose and Sinuses: Nose is symmetrical, with patent vestibules, mucosa is pink, moist; septum is at the
midline and intact, turbinates are not congested, no discharge, no tenderness over the frontal and
maxillary sinuses.

Mouth and Oral Cavity: lips are moist, buccal mucosa and gums are pink, moist; no plaques or ulcers.
Tongue is at the midline, dry, no fasciculations. Hard and soft palate are pinkish, no lesions; uvula is at
midline. Tonsils are not enlarged; pink tonsillar walls with no exudates

Neck: supple, symmetrical, no neck vein engorgement, normal muscle development and tone, trachea in
midline, soft, no palpable cervical lymph nodes.

Lungs/Chest: Symmetrical chest expansion, no lagging, no intercostal retractions, vesicular breath

sounds, no wheezes and rhonchi.

Heart: Adynamic precordium, no heaves nor thrusts, no palpable thrills. The apex beat is at the 5th
intercostal space left mid clavicular line, tachycardic, irregularly irregular rhythm. S1 is variable. S2 best
appreciated at the base, no murmur, no S3 or S4.

Abdomen: Globular, no superficial blood vessels, inverted umbilicus, normoactive bowel sounds, no
bruits, tympanitic in all quadrants on the epigastric and lumbar areas, liver span of 7 cm, no palpable
mass, non-palpable spleen, non-tender, no costovertebral angle tenderness.

Extremities: No gross deformities, full and equal pulses, no edema

NEUROLOGIC EXAMINATION:

Cerebrum: GCS 15, conscious, coherent, oriented to time, place, person with intact immediate, recent
memory
Cerebellum: No nystagmus, no ataxia, negative Romberg’s test, no dysmetria, no dysdiadochokinesia

Cranial Nerves
CN I: Not assessed
CN II: Pupils 2-3mm equally reactive to light
CN III, IV, VI: Intact extraocular muscles
CN V: Can clench teeth
CN VII: No facial asymmetry
CN VIII: no lateralization on Weber’s test
CN IX, X: Uvula is at midline, (+) gag reflex
CN XI: Equal shoulder shrug, bilateral
CN XII: Tongue is at midline; no fasciculations

Pathologic reflexes:
No Babinski