Medicina

MEDICAL HISTORY
FILIATION DATA
NAME AND LAST NAME: SILVIA MIÑARCAJA
AGE: 35
GENDER: FEMALE
BIRTH DATE: MAY 6, 1977
BIRTH PLACE: MACHALA
ETHNICITY: MESTIZO
RELIGION: CATHOLIC
MARITAL STATUS:SINGLE
INSTRUCTION:
OCCUPATION
CURRENT RESIDENCE
HABITUAL RESIDENCE
ADDRESS

REASON FOR ADMISSION OR QUERY
Precordial pain
HISTORY OF PRESENT ILLNESS
Patient reports that clinical picturestarts a few months ago with stitches in chest region while riding bike then presents pain a week ago, after anger itself is removed at once. then the cycling has pain again in the same region but moreintensely oppressive type, without irradiation lasting approximately an hour and a half, accompanied by cough, sputum white, cold sweats, and sore throat, burning the precordium and nausea.
Thepatient did not present any discomfort from your income after taking drugs.
PAST HISTORY
Smoking: from 15 years with a consumption of 2-3 packs a day.
Alcohol: from 15 years with a consumption of 1 amonth 5 glasses.
Allergies: penicillin.
FAMILY HYSTORY
Mother: brain tumor, type II diabetes mellitus, hypercholesterolemia, hypertension.
Father: HTA, first thrombosis at age 50 that left himcrippled, with a fatal recurrence 7 years later.
Siblings: several with hypertension and heart disease unspecified.
SOCIAL HYSTORY
Housing: with all basic services, 4 rooms, no pets.
REVIEW OF THESYSTEMS
RESPIRATORY SYSTEM (RS)
* Inspeccion: Normal appearing chest
* Probing: Dishinished vocal vibrations. Expandability and elasticity disminished.
* Percussion: Dullness
*Auscultation: Dishinished breath sounds. Hoarse and sibilant rales scattered in both hemithorax.
CARDIOVASCULAR SYSTEM (C.V)
* Inspeccion: Shock the follow point.
* Probing: Not palpable shock edge.* Percussion: Cradial dullness.
* Auscultation: R1 and R2 rhythmic and coordinated with the pulse.
GASTROINTESTINAL SYSTEM (G.I)
* Inspeccion: Abdomen symmetric, depressible, sof,...