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Here is a well-structured clinical history based on the notes:
CLINICAL HISTORY
Name: Zakia Bibi
Age: 85 years
Address: Malakand
Date of Admission: 23rd April 2024
CHIEF COMPLAINT
Right-sided chest pain — since last night at 1:00 AM
HISTORY OF PRESENTING ILLNESS
An 85-year-old female from Malakand presented to the OPD/Emergency with a complaint of right-sided chest pain that began suddenly last night at 1:00 AM.
Using SOCRATES framework:
- Site: Right side of the chest
- Onset: Sudden
- Character: Sharp in nature
- Radiation: Does not radiate (note: radiation to the arm/head was crossed out and negated)
- Associated symptoms: Associated with nausea
- Timing: Pain is constant, with no relieving or exacerbating periods
- Exacerbating/Relieving factors: Movement makes the pain worse; no relieving factors noted
- Severity: Patient rates the pain 7–8/10 on a visual analogue scale (0–10)
Medications given prior to assessment: Nibs, Zapirt (as noted)
SYSTEMIC REVIEW
- Cardiovascular/Respiratory: No significant findings
- Gastrointestinal: Nausea present; pain in the epigastric region
PAST MEDICAL HISTORY
| Condition | Duration |
|---|---|
| Hypertension (HTN) | 20 years |
| Diabetes Mellitus Type 2 (DM²) | 20 years |
| Chronic Kidney Disease (CKD) | 3 years |
PAST SURGICAL HISTORY
- Cholecystectomy (date not specified)
FAMILY HISTORY
- Father and Mother both had Diabetes Mellitus and Hypertension
DRUG HISTORY
| Drug | Dose/Notes |
|---|---|
| Norvasc (Amlodipine) | — |
| Survesdo | — |
| Rosuvastatin | — |
| Aspirin | 75 mg |
| Lasix (Furosemide) | 20 mg |
| Pregabalin | — |
| Lophor | — |
PERSONAL HISTORY
- Sleep: Normal
- Appetite: Normal
- Socioeconomic status: Good
Clinical Note: Given the patient's age (85), sudden-onset right-sided chest pain with epigastric pain and nausea, background of HTN, DM, CKD, and her current medications (statin, aspirin, CCB), differentials including acute coronary syndrome, pleuritis, pulmonary embolism, and referred pain from a GI source should be considered and worked up accordingly.
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