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  • BP: 150/100 RR:26 Spo2-85%

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    ambiit25
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    This document summarizes the assessment of a 65-year-old male patient, Antonio Luna, who presented with chest pain. Upon examination, the patient's skin was pale and cold with no cyanosis, his heart and lung sounds were abnormal, and vital signs were elevated. The patient became uneasy due to worsening chest pain. He was referred to the doctor for further evaluation and treatment due to a history of hypertension and smoking, and current presentation of severe chest pain.

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    This document summarizes the assessment of a 65-year-old male patient, Antonio Luna, who presented with chest pain. Upon examination, the patient's skin was pale and cold with no cyanosis, his heart and lung sounds were abnormal, and vital signs were elevated. The patient became uneasy due to worsening chest pain. He was referred to the doctor for further evaluation and treatment due to a history of hypertension and smoking, and current presentation of severe chest pain.

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    5 views1 page

    BP: 150/100 RR:26 Spo2-85%

    Uploaded by

    ambiit25
    This document summarizes the assessment of a 65-year-old male patient, Antonio Luna, who presented with chest pain. Upon examination, the patient's skin was pale and cold with no cyanosis, his heart and lung sounds were abnormal, and vital signs were elevated. The patient became uneasy due to worsening chest pain. He was referred to the doctor for further evaluation and treatment due to a history of hypertension and smoking, and current presentation of severe chest pain.

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    of 1

    PATIENT: LUNA, ANTONIO 65Y/O

    SCENE 1:

    HI SIR …

    SCENE 2: ASSESSMENT

    SIR IM GOING TO ASSESS U PO FOR FURTHER RESULTS PO AND PARA MAKITA NATIN IF THERE IS
    ANY ABNORMALITIES. THERE IS A TIME PO SIR NA HAHAWAKAN KO PO KAYO AND WAG PO KAYO
    MABIBIGLA, DI NAMAN PO MASAKIT YUNG ASSESSMENT NA GAGAWIN KO.

    INSPECTION: SKIN IS PALE, COLD, NO CYANOSIS, SCARS NOTED

    PALPATION &PERCUSSION: NO MURMUR, HEAVES NOTED, PMI IS PRESENT, AND NO


    DISTENDED NECK VEINS

    AUSCULTATION: PRESENCE OF CRACKLES UPON AUSCULTATION (RETENTION OF PHLEGM IN


    THE LUNGS)

     HR: 70 BP: 150/100 RR:26 T-37.2 SPO2-85%

     NAIL POLISH NEEDS TO BE REMOVE TO NOTICE IF THERE IS …

    PT BECOMES UNEASY BC OF CHEST PAIN

     RATE CHEST PAIN (PQRST)


     DESCRIBE IF DULL, SHARP, STABBING
     LOCATION OF PAIN ? DOES IT RADIATE?

    SCENE 3: REFER TO DOCTOR

     HI DOC BASAT, IM CALLING TO REFER PT LUNA, 65 Y/O PT WHO WAS ADMITTED IN


    MEDICAL WARD ROOM 226, FOR EXPERIENCING SEVERE CHEST PAIN.
     MR. LUNA HAS A HX OF HYPERTENSION FOR 30 YRS AND HE IS A SMOKER FOR 10 YRS
     HE WAS RUSHED TO THE HOSPITAL BY HER WIFE WHILE GARDENING HE AGAIN
    EXPERIENCE SEVERE CHEST PAIN.
     VS: BP: 150/100 PR :70 RR: 26 T: 37.2 SPO2:85%
     PAIN SCALE OF 10/10

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