3. PATIENT IDENTIFICATION
Name; JOHN AMBO
Sex ; Male
Age; 65 YEARS OLD
Place Residence; FINCH ROAD
Province; EASTERN HIGHLANDS PROVINCE
Religion; LUTHERAN CHURCH
Source of History; PATIENT HIM-SELF
Date of Admission: 26TH / APRIL/ 2023
Time of Admission; 12: p.m. MID-DAY
Rout of admission; EMERGENCY DEPARTMENT MPHA
Date of discharge; 1st / MUCH / 2023
Inpatient days; 4 days
4. PRESENTING SYMPTOMS
Dizzy x 4/12
Shortness of breath on exertion x 4/12
Lower limb swelling x 2/52
HISTORY OF PRESENTING ILLNESS
The patient was initially well until x 4/12 before the
admission he developed dizziness and shortness of
breath on exertion especially when doing physical
activities or exercises. On x 2/52 before the admission,
he developed bilateral lower limb swelling which
makes him unable to walk, thus presented at The
Accident and Emergency Department (MPHA) on the
26th of April 2023 at around 12:p.m. (mid-day).
5. SPECIFIC INTEROGATION
No night sweat
No weight loss
No cough/ chest pain
No orthopnea/ Paroxysmal nocturnal dyspnea
No palpitation
Head ach (mild) at times
No intermittent fever
Normal bowel and bladder function
6. Past medical history
First admission
Not on any treatment/medication
A known Lymphadenopathy patient completed His TB
dose for x9/12.
Food and drug allergy
No food and drug allergies
Family history
Denies family major illness in the family
(TB/ASTHMA/DMT2/HTN)
Social history
LD Logistic driver
Married
Consume alcohol, betel-nut accept cigarette
