Scribd
Upload
5K views8 pages

Biodata of The Patient

The document contains the patient history and examination findings for a patient admitted to Civil Hospital, Jalandhar with chief complaints of [blank]. It includes the patient's biodata, medical history, physical examination, diagnostic tests, disease description, nursing assessment, and health education provided. The patient's vital signs, lab investigations and current medications are documented. The physical examination notes the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities and systemic assessment.

Uploaded by

Ruchika Kaushal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
5K views8 pages

Biodata of The Patient

The document contains the patient history and examination findings for a patient admitted to Civil Hospital, Jalandhar with chief complaints of [blank]. It includes the patient's biodata, medical history, physical examination, diagnostic tests, disease description, nursing assessment, and health education provided. The patient's vital signs, lab investigations and current medications are documented. The physical examination notes the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities and systemic assessment.

Uploaded by

Ruchika Kaushal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 8

History of the Patient

Biodata of the Patient

Name :
Age :
Gender :
IPD Number :
Education :
Occupation :
Marital Status :
Religion :
Address :
Ward :
Date of Admission :
Diagnose :
Dr. Incharge :
Hospital :

Chief Complaints:
Patient named came to Civil Hospital, Jalandhar on with the chief complaints of:

Present History:
 Present Medical History: Patient named is admitted to Civil Hospital, Jalandhar with
present medical complaints of
 Present Surgical History: Patient had not undergone any kind of surgery.

Past History:
 Past Medical History: Patient is not having past medical history of TB, Diabetes, HIV,
Jaundice or any other disease.
 Past Surgical History: Patient had not undergone any kind of surgery in past.

Family History:
There are total members in patients family. Patient belongs to nuclear joint family.
Patient is the only source of income in his family.

Family Tree:

Keys:
= Female = Patient

= Male = Patient

= Dead Person

Family Biodata:
Sr. Name Age/ Education Occupation Relation Remarks
No Gender with
. Patient

Personal History of the Patient:


 Dietary Pattern: Patient is vegetarian. Patient is taking Semi-solid Diet.
 Elimination Pattern: Patient is catheterized. Urine output is measured by urobag. Stool
is passed by patient.
 Sleeping Pattern: Sleeping pattern of patient is disturbed due to hospitalization and pain.
 Socio-economic Status: Patient is living in pucca house. There is proper lightening and
drainage facilities in patient’s home.
 Addiction: Patient is not addicted to any kind of addiction like drugs, alcohol, smoking,
tobacco etc.

Vital Signs:
Sr. Vital Signs Normal Value Patient’s Value Remarks
No
.
1. Temperature 97-99ºF ºF
2. Pulse 60-100 beats/min beats/min
3. Respiration 16-24 breaths/ min breaths/ min
4. Blood Pressure 110/70 – 140/90 mmHg mmHg

Lab Investigations:
Sr. Tests Normal Value Patient’s Value Remarks
No
.

Medications:
Sr. Trade Name Pharmacological Dose Rout Frequency Action
No Name e
.

Physical Examination
General Appearance
Orientation :
Consciousness :
Activity :
Look :
Nourishment :
Body built :
Health :
Activity :
Posture
Body curve :
Movement :
Skin
Color :
Texture :
Temperature :
Lesions :
Head and face
Shape of the skull :
Scalp :
Face :
Hair color :
Eyes
Eyebrows :
Eyelashes :
Conjunctiva :
Sclera :
Cornea and iris :
Pupils :
Lens :
Vision :
Ears
External ear :
Nostrils :
Sense of smell :
Mouth
Lips :
Odour of mouth :
Teeth :
Tongue :
Nose
Nasal septum :
Discharge :
Throat and pharynx
Neck :
Lymph nodes :
Range of motion :
Chest
Chest symmetry :
Breath sounds :
Abdomen
Palpation :
Bowel sounds :
Lesions :
Pain :
Extremities
Upper Extremities
Mobility :
Alignment :
Range of motion :
Lower Extremities
Mobility :
Alignment :
Range of motion :
Systemic Examination
 Respiratory System
Respiratory Rate :
Dyspnea :
Breath sounds :
 Neurological System
Orientation :
Consciousness :
Mental status :
 Cardiovascular System
Heart rate :
Blood pressure :
Heart sounds
 Musculoskeletal System
Body symmetry :
Range of motion :
Gait :
Movement :
 Gastrointestinal System
Appetite :
Abdominal pain :
Constipation :
Bowel sounds :
Stool :
 Genitourinary System
Voiding :
Urine output :
Anatomy and Physiology

Disease Description
Introduction:
Definition:
Etiology:
In Book In Patient

Pathophysiology:
Clinical Features:
In Book In Patient

Diagnostic Tests:
In Book In Patient

Medical Management:
In Book In Patient

Surgical Management:
In Book In Patient

Nursing Assessment
Nursing Diagnosis
Short Term Goals
Long Term Goals
Health Education:
 Personal Hygiene:
 Nutritional Habits:
 Rest and Sleep:
 Medication:
 Follow-up: Patient is advice to do regular follow-up.

You might also like