MARY JOHNSTON HOSPITAL

1221 Juan Nolasco Street, Tondo, Manila 1012

Tel Nos. (632) 245-4021 to 25 Fax No. (632) 245-4487
PhilHealth Accredited

Hospital Case No. 364951 Last Name: LIWANAG Date Of Birth: January 07, 1983
Date of Admission: 04/07/2018 First Name: ARLAN Age/ Gender: 35/M
Attending Physician: Dr. Alkuino/ Middle Name: CORADO Civil status: MARRIED
Dra.Sevilla

Chief Complaint: Chest Pain

History of Present Illness: Patient is a 35/M with good functional capacity came at the ER due to chest pain.

2 hours prior to consult: (+) chest pain, associated with difficulty of breathing patient was immediately rushed at our institution
and was subsequently admitted.

Past Medical History: Family Medical History: Personal & Social History:
(-) HPN (-) Heart Disease (- ) Asthma (+)MI Father (-) Cancer (-) Smoker
(-) Dm (-) PTB (- ) Allergy (-) DM (-) Asthma (-) Alcoholic Drinker
(-) UTI (-) PTB (+) CAD (-) Substance Abuse

Review Of Systems:
(-) Fever (-) Headache (-) Dizziness (-)SOB/DOB (- ) Cough (- ) Colds ( ) Chest Pain (- ) Orthopnea (-) Easy Fatiguability
(-) Vomiting (-) LBM (-) Abdominal Pain (-) Dysuria (- ) Hematuria (- ) Melena (- ) Hematochezia
(- ) Body Weakness (-) Edema ( -) Weight Loss
Physical Examination: Medications given and administered while
Vital signs: BP: 130/70 HR: 102 RR: 23 Temp: 36 C O2: 98% admitted:
General: Conscious, Coherent 1. ASA 80 mg/tab OD
Head and Neck: Anicteric Sclerae, Pink Palpebral Conjunctiva, Pink Oral Mucosa 2. Clopidogrel 75 mg/tab OD
Chest: Symmetrical Chest Expansion, (-) Retractions, clear breath sounds 3. Atorvastatin 80 mg/tab ODHS
Cardio Vascular: Adynamic Precordium, Normal Rate, Regular Rhythm, (-) Murmur 4. Fondaparinux 2.5 mg Now then OD
Abdomen: Flabby, Normoactive Bowel Sounds, Soft, Nontender 5. Omeprazole 40 mg TIV OD
Extremities: Full and Equal Pulses, (-) Edema, (-) Cyanosis 6. Carvedilol 6.25 mg/tab 1 tab Od
7. KCL 1 tab TID for 9 doses
8. Perindopril 5mg/ tab OD
9. ISMN 30 mg/tab OD

Laboratory & Diagnostics Examination:

 Please allow patient’s relative to photocopy Laboratory Results for Future Reference.

(Course in the Ward)

Upon admission patient was admitted at MICU, Hook to O2 at 2LPM, Diagnostic work up was conducted, Vital Signs were strictly
monitored. Medications administered as stated above during admission. Patient’s chest pain was relieved, Vital signs were stable. Repeat
ECG was done STEMI V1-V4 Inferior Wall MI. Trop I negative.

2nd Hospital day patient was trans out to room of choice, No chest pain, no difficulty of breathing, no shortness of breath, Vital signs were
stable.

3rd Hospital Day, Patient was comfortable, No Chest pain, No Difficulty of breathing, No Shortness of breath. Vital signs were stable, repeat
diagnostic work up were normal. Patient clinically improved. Patient was Discharged and Advised to continue maintenance medications.

Patient went home April 11, 2018

Final Diagnosis: Acute Coronary Syndrome, STEMI, Inferolateral wall Killip I, CKD stage II

Dr. Alkuino/Dr. Sevilla James Belgira Tamayo 04-18-201

Consultant- In-Charge Resident-In-Charge Date Accomplished

-NOT VALID FOR MEDICOLEGAL PURPOSE-

rev04.28.2016mjhform