MEDICAL CASE REPORT

PATIENT INFORMATION

Name Age
Mr. X 50

Phone Number Date of Birth

(021) 112-2334 March 10, 1950

Email Gender
adamadam111@gmail.com Male

Address
111 wall street, suite 1122,
san francisco, CA, 22111

Emergency Contact Person Civil Status

Mrs. Y Married

Emergency Contact Person Phone

(021) 112-2334

Admission Date
March 2, 2020

Chief Complaint
My legs are swollen up. I'm having a hard time breathing when I'm lying on the bed.
I can also feel the heaviness on my chest even if I'm not doing anything.

Current Medical History

Patient in experiencing irregular heart rhythm. No previous history of
hospitalization. No previous history of surgery. Patient has history of asthmatic
attacks.

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Name Purpos Dosage Frequency

e
Vitamins And
1 Maintaining health 1 tablet Daily
Supplements

2 Calcium Maintaining health 1 tablet Daily

3 Celestamine For allergy attacks 1 tablet As needed

Smoking Alcohol Consumption

No No

Substance Abuse
No

Allergies

Allergic the seafood but it is just moderate and it can be treated with medicine
table.

Family History - Please list down below if you have any

Family history of hypertension and asthma

Past Medical History

No previous history of hospitalization. No previous history of surgery. Patient has
history of asthmatic attacks.

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Vital Signs

Temperature Blood Pressure Heart Rate Respiratory Rate

1 37.0 120/90 85 20

REVIEW OF BODY SYSTEMS

Normal Abnormal Remarks

Sensory

Irregular heart
Cardiovascular
rhythmn

Hard to breath
Respiratory
at times

Digestive

Skin/Integumentary Edema on right foot

Bone

Spinal Cord

Neurological

Joints

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CURRENT MEDICAL CONDITIONS

None Yes I'm not sure

Eye problems

Seizures

Epilepsy

Hearing problems

Diabetes

Cardiovascular disease

History of Stroke

Respiratory problems

Kidney problems

Stomach ad liver problems

Pancreatic problems

Anxiety and depression

Other mental health issues

Sleep disorders

Neck or back problems

CLINICAL DIAGNOSIS

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DIAGNOSTIC EXAMINATIONS

Procedure Name Purpose Result

1 Chest x-ray Check lungs Normal

2 Urinalysis Check urinary tract Normal

3 Fecalysis Check for infection Normal

4 Kidney test Check functionality Normal

5 Ultrasound Check position Enlarge

TREATMENT

The patient needs to be admitted to the hospital for monitoring purposes. The
patient will undergo diuretic to remove excess fluid in the body.

Physician Name Physician Signature

Mr. Z

Date Signed
Monday, March 2, 2020