case presentation(cardio pd)
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Case Presentation
Nabilah Dato’ AyobNur Hanis Mohamad
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Personal IdentificationName : Zaharah Mat
Age : 63 y.o
Address : Kangar
Religion : Islam
Occuptn : Not working
Date Admitted : 1/10/2010 (from emergency)
The history was taken from the patient herself.
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Chief ComplaintShortness of Breath• Started (3 days ago), happen while resting• Relieved by lying down/No aggravating factors• Accompanied by coughing (non productive), no fever• Needed 2 pillows to sleep at night
Chest Pain• Started (4 days ago), complaint of mild pricking pain on her left
chest area• Sudden onset, while resting roughly 30 minutes of duration • Relieved by lying down and GTN sublingual/ no aggravating
factors• Complaint of palpitation otherwise, no sweating and oedema
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Past medical History
• IHD (HTF), pt.can’t remember when she was diagnosed• Said she was admitted many times before in HTF due to
her heart problem, but can’t remember the 1st time and last time she was admitted
Heart Disease
No DM
No Hypertension
No Renal diseases
No Surgical Intervention was done
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Drug Historry
Currently on IHD medication• Claimed compliance to medication• Doesn’t bring the previous medication, and
does not know the name of medication, except for her Sublingual GTN
Allergies• Said she has no allergic to any foods or drug
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Family History
Her father died Hypertension
Her Mother Natural Causes
Clean bill of health on her
sibling s and child
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Social History
Non smoker Non alcoholic Non Smoker husband
Non asthmaticControlled
nutrition due to IHD