Sei sulla pagina 1di 5

HISTORY TAKING OF PATIENT WITH

TUBERCULOSIS

SUBMITTED TO
MISS NAZIMA BHATTI
(Lecturer)

SUBMITTED BY
NAVPREET KAUR MSC nursing 1st year

Department of Medical Surgical Nursing

Medical surgical nursing

BIO DATA OF THE PATIENT


NAME AGE SEX ADDRESS WARD MARITAL STATUS NATIONALLY RELIGION EDUCATION OCCUPATION DATE OF ADMISSION TIME OF ADMISSION DR. IN CHARGE DIAGNOSIS CHIEF COMPLAINTS Patients name Mr. Malkeet Singh Maan. He is coming in hospital on morning time 5: am. The patient CHIEF COMPLAINTS ARE : Fever Cough Weakness Vomiting 1month 2 weeks 1month 5days Malkeet Singh Maan 45 years Male Bank colony Jalandhar ICU Married Indian Sikh Metric Farmer 28-3-2012 5:00 am Dr. Jaswinder Singh TUBERCULOSIS

PRESENT MEDICAL HISTORY He is suffer from fever cough weakness & communication disease Tuberculosis PRESENT SURGICAL HISTORY There is no any significant surgical

PAST MEDICAL HISTORY Patient had fever caught weakness for last month PAST SURGICAL HISTORY Patient had a surgical of a chest last 2 month PERSONAL HISTORY Patient is vegetarian He is the habited of watching T.V He is able to take food orally. FAMILY MEDICINE HISTORY There is no any significant No any communication disease of other family member No any infection wound or injury FAMILY SURGICAL HISTORY There is no any significant there is no any family surgical history VITAL SINGS S no 1 2 3 4 Vital sings Temp Pulse Respiration B.P Normal value 98.6F 72-80/min 16-24/min 120/180/mm hg Pts value 101F 74/min 28/min 130/60mm hg Remarks Increase Normal Increase increase

LAB INVESTIGATION S no 1 2 3 Blood sugar HB Serum birubin 70-140mg/dl 12to14mg/dl 0.01-10mg 146mg/dl 8.2mg/dl 0.10mg/dl Increase Decrees Normal

MEDICATION S no 1 2 3 4 Drug name Inj deriphylin Inj metrapt Tab PCM Tab ractina Route IV DOSE TIME Action Bronchodilators Antibiotics Antipyretics Anti

6.mg/dl BD BD TDS BD

IV 2ml Orally 280mg Orally 600-

300mg

tuberculosis

PHYSICAL EXAMINATION
GENERAL APPEARANCE Patient is not well nourished Body builds also unhealthy due to weakness Acuity is not good MENTAL STATUS Patient is conscious He is co- operative SKIN Color Texture Head & face Skull shape is normal no, any injury is present hair color is black face impression is not good EYES Eyes are normal EARS No any discharge is present NOSE Nose is not running Black clear

MOUTH No, bad smell is present TEETH Teeth are normal but some disparage NECK

Neck movement is normal CHEST Chest movement is normal but some sound is present ABDOMEN Abdomen shape is normal no any injury HEALTH EDUCATION Give health education to the patient about personal hygiene Give health education about mouth care Advice the patient about home care Advice the patient change daily dirty clothes Give the health education advantage of nutrition Teach the patient importance of balance diet Teach the patient about not to take heavy food Give health education contains sugar restricted food