Case Presentation

Nabilah Dato’ AyobNur Hanis Mohamad

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.

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

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

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

Family History

Her father died Hypertension

Her Mother Natural Causes

Clean bill of health on her

sibling s and child

Social History

Non smoker Non alcoholic Non Smoker husband

Non asthmaticControlled

nutrition due to IHD