Patient X is a 76-year old female, widowed at age 75 and has 8 grown-up children, 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? Y: The condition stayed the same.

- - - - - - - - - - Past Medical History Me: Any hospital admissions of your mom, Maam? Y: Yes, she was admitted 5 years ago because of increased blood pressure Me: Any operations? Y: None. Me: Any history of rheumatic fever or heart problems as a child? Y: None. Me: Any illnesses that seem to run in your family? Y: Her younger brother was diagnosed at age 14 years with dilated cardiomyopathy that resulted in death three weeks following the onset of severe acute congestive heart failure. Two other siblings and her parents are free of heart disease. Me: Okay Maam, is she a smoker or an alcohol drinker? Y: Yes, she smokes a lot. In a day, she can finish 2 packs of cigarette and regularly, she drinks a bottle of Gin. Me: How about the foods she eats regularly? Y : She was fond of eating laman-loob and salty foods such as butong-pakwan and some chichirya as her pulutan Me: Does she have a regular exercise? Y: None. Me: What does she do every day? Is she still working? Y: She just stayed in our house with my siblings and her grandchildren. She was a retired teacher. Me: Any medications she is taking? Y: She has a daily intake of Simvastatin. Me: Thank you for all the information Maam. Do you want to be confined here so we can for further observations? (Referring to Patient X) Patient X: Yes please. 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 AND APENDAGES

Skin (Inspection)

-bluish discoloration to the lips and extremities. -presence of edema

Hair (Inspection)

-unevenly distributed-slight dryness noted- dandruff is noted

Nails (Inspection)

-long and dirty-slightly cyanotic in color upon assessment-capillary refill time is 3 seconds -clubbed fingers

HEAD AND NECK (Inspection)

Head(Inspection)

-symmetrical in size and shape-no signs of lesions and nodules-no flakes-no rashes

Face(Inspection)

-symmetrical both in shape and movements-vesicles and acne scars noted-some reddened papules are noted- (-) edema on face- (-) tenderness

Eyes and Vision- sclera is anecteric (Inspection)

-patient is not wearing an eyeglasses or contact lenses upon assessment-eyelids close symmetrically upon observation-pupils are black and reactive to light-pupils size is 6 millimeter eyebrows have even distribution of hair -pinkish conjunctiva

Ears and Hearing (Inspection)

-ear colour is same as facial skin-symmetrical in size, shape and alignment-no exudates noted and presence of cerumen on both ears-able to hear and repeat words given through voice whisper test

Nose and Sinuses (Inspection)

- (+) clear watery discharges-no tenderness and masses noted

Mouth and Pharynx (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)

-symmetrical in size and shape-no nodules and lesions upon assessment

THORAX AND CHEST (Inspection&Auscultation) -has a productive cough -difficulty in breathing noted -RR= 30 cycles/minute

-Use of accessory muscles -Dyspnea on exertion

Heart (auscultation)

Visible Lifts and Heaves are caused by clients illness