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As Far As I Know, She Did Not Have Any.: - Present Medical History
As Far As I Know, She Did Not Have Any.: - Present Medical History
accompanied by Y, her oldest child, had been admitted to Dr. PJGMRMC with a chief
complaint chest pain.
Me: Good afternoon Maam, I am Geramei V. Tejada, the nurse on duty. May I ask
some personal information regarding to your mothers past and present medical
condition?
Y: Yes you may.
Me: Ok, so what is her full name?
Y: XXX
Me: And her age please?
Y: 76 years old.
Me: Where do you live?
Y: Jaen, Nueva Ecija.
Me: What is her religion?
Y: Roman Catholic
Me: Does she have any allergies?
Y: As far as I know, she did not have any.
Me: Does she have an existing medical condition?
Y: Yes, Hypertension.
- - - - - - - - - - Present Medical History
Me: You go here at PJG hospital with a chief complaint of chest pain, may I ask when
did it all start?
Y: Just few hours before we went here, she was just watching TV with her
grandchildren when she shouted that she was experiencing chest pain and
uncomfortable breathing.
Me: For how long she has been experiencing that?
Y: These last few days her chest pain become more severe but she can still handle
the pain but now she cant.
Me: Has it gotten worse/better or stayed same over that time frame from your
house til you arrived here to the hospital?
Me: Okay Maam. To have a further assessment, can we now perform the Physical
Assessment?
Patient X: Yes. Thanks also.
- - - - - - - - - -Physical Assessment:
VITAL SIGNS
Temp: 36.8C
HR: 110 beats per minute
RR: 36 cycles per minute
BP: 130/80 mmHg
Skin (Inspection)
Hair (Inspection)
Nails (Inspection)
Head(Inspection)
-symmetrical in size and shape-no signs of lesions and nodules-no flakes-no rashes
Face(Inspection)
>Lips:- dark colored lips- dry, cracked lips upon assessment- dry mucous
membranengue:- pinkish in colour >Teeth:- plaque noted- yellowish in color >
Gums:- dark in color > Breath- halitosis noted
Neck (Inspection)