HISTORY TAKING OF PATIENT WITH

ANGINA PECTORIS

SUBMITTED TO
SUBMITTED BY MISS NAZIMA BHATTI
NAVPREET KAUR
(Lecturer)

MSC nursing 1st year Medical surgical nursing

Department of Medical Surgical Nursing

BIODATA OF THE PATIENT

NAME AGE SEX ADDRESS WARD MARITAL STATUS EDUCATION OCCUPATION NATIONALITY RELIGION DATE OF ADMISSION TIME OF ADMISSION DR INCHARGE SISTER INCHARGE DIAGNOSIS

Jaswant Singh 45yrs Male Jyoti Chowk, Jalandhar Emergency Married 12th Farmer Indian Sikh 12-April-2012 10:15am Simranjeet Kaur Pawan Kumari Angina pectoris

CHIEF COMPLAINTS
Mr. Jaswant singh come to civil hospital Jalandhar with chief complaints of chest pain radiate to shoulder x4 days Dyspnoea x2 days Numbness in the left shoulder x2 days Headache since 2 days

MEDICAL HISTORY
PRESENT MEDICAL HISTORY Patient is admitted to the civil hospital Jalandhar with the complaints of chest pain radiate to shoulder Dypnoea, numbness, in the left shoulder and arm, headache. PAST MEDICAL HISTORY There is no any past medical history

SURGICAL HISTORY

PRESENT SURGICAL HISTORY No any significant evidence of surgical, procedure. PAST SURGICAL HISTORY There is no any surgical procedure in past is performed.

FAMILY TREE

Patient 45 Years Wife 40 Years

Son 22 Years Daughter 15 Years

PERSONAL HISTORY Mr. Jaswant Singh has no any bad habit. His personal hygiene is good. His bowel and bladder elimination pattern is normal. He is not able to perform activities like walking, exercise etc. NUTRITION HISTORY Mr Jaswant singh is non vegetarian. He took his meal twice a day. He is an alcoholic but he has any habit of smoking He dont have any allergy from any food. SOCIOECONOMIC STATUS Mr Jaswant Singh is belongs to middle class family. He lives in a rural area in a pucca house and there is good sanitary condition and facilities.

PHYSICAL EXAMINATION General appearance Nourishment Body build Health Activity Well Nourished Thin Normal Dull

Mental Status ConsciousnessLook Conscious Anxious , Suppressed

Posture Body curve Movement Normal Restricted

Height & weight Height Weight 55 80 kg

Skin Condition Color Texture Temperature Lesion Fair Dryness Normal Absent

Head & face Eyes Nose No any discharge No any Septal defect Eye brows Eyelids Conjunctiva Sclera Normal No any edema Normal No jaundice Scalp Pediculosis Brown colour of hair Absent

Mouth & Pharynx

 Neck Chest

Lips Odors & mouth Teeth Pharynx

Cracking on lips Foulness Normal No any enlargement

Lymph node Thyroid gland Range of motion

Palpable Normal Limited

Thorax Heart Breath sound

Normal Normal shape Wheezing

Abdomen Inspection Distended Abdomen

Palpation

No spleenomegaly

Extremities Movement of joint Normal Tumor Absent Systemic Assessment Cardio Vascular system Chest pain present Dyspnea Hypertension Bradycardia Numbness Headache

Vital signs S No 1 2 3 4 Vital signs Temperature Pulse Respiration Blood pressure Pt value 98.6 72-84/min 16-22/min 120-80mmhg Normal value 89.6F 72-84/min 16-22/min 120mmhg Remarks Normal Bradycardio Tachycardio Hypertension

Lab investigations SNO 1 2 3 4 5 Test Hb RBC WBC Platlets Screatinine Patient value 10gm/dl 3.0million 12000mm3 270000cm 1.5mg/dl Normal value 12-16gm/dl 4-6million 4000-11000mm3 15,000-400000 4-1.2mg/dl REMARKS mildanaemie Decrease Leureoujtosis Normal Increase

Medications SNO 1 2 3 4 5 6 Drug Tab paracetamol Tabdictofenac Inj voveran Inj omnatax Inj Tabramicin Inj Ampiailun Dose 500mg 100mg 1gm 1gm 80mg 25mg Route Arally Arally In Iv Iv Iv Frequency BD BD Stat BD BD BD Actoin Antigreties Analgesics Analgesics Antibiotic Antibiotic Antibiotic

SUMMARY
Mr Jaswant Singh 45 years old and was admitted in civil hospital Jalandhar in emergency ward x chief complaints of Chest pain radiate to should x4days Dyspnaeax2days Numbness in left shoulder x2 days Headache since 2 days

The doctor diagnosed him as Angina pectoris He prescribed him following medication Inj Gentamycin 10mg Inj Voveran 1.5ml Inj Complains 150mg Tab Aspirin 500mg