University:
West Coast University
Course:
NURS 100 | Fundamentals of Nursing
Academic year:

2021
Views:

14

Pages:

3
Author:

Ryann Brock

History of Patient Data of the Patient: Patient Name: Mr. Gurudev Singh Age: 80 years Sex: Male CR No: 10546 Bed No: 04 Ward No: Male ward Religion: Sikh Education: Uneducated Marital Status: Married Occupation: Farmer Address: Lehra Mohammad, District Bathinda Dr. Incharge: Dr. Sudhanthu Diagnosis: Myocardial Infarction (MI) Date: 25/02/2021 Chief Complaints: Patient came to the hospital with chief complaints of: Headache for 3 days Weakness for 3 days Sweating for 3 days Chest pain for 1 month (radiating to the shoulder and left arm) Present Medical History: Patient came to the hospital with complaints of chest pain, sweating, headache. He was admitted under the supervision of Dr. Sudhanthu and came to the emergency ward. Present Surgical History: No significant surgical history. Past Medical History: Patient is suffering from diabetes mellitus. No history of hypertension, asthma, or tuberculosis. Past Surgical History: Patient has no significant past surgical history. Personal History: Patient is a vegetarian and does not take any drugs or alcohol. He has no habit of smoking. Oral hygiene: Good Brushing: Once a day Bath: Twice a day Diet: Vegetarian Bowel elimination: Once a day Marital Status: Spouse Health: Good Spouse Occupation: Housewife Family History: The type of family is a joint family. There are 5 members in the family. All family members are physically and mentally well, but Mr. Gurudev Singh is suffering from myocardial infarction. Type of Family: Joint family Number of Members: 05 Head of Family: Gurudev Singh Family Chart: Name Age/Sex Occupation Education Relation Marital Status Gurudev Singh 80/M Farmer Nil Self Unhealthy Gupreet Kaur 76/F Housewife Nil Wife Healthy Mahinder Singh 50/M Farmer Matric Son Healthy Mandeep Kaur 47/F Housewife Matric Daughter-in-law Healthy Sardeep Kaur 20/F Student BSc 1st Yr Grand Daughter Healthy Family Tree: [Gurudev Singh (Patient)] -- [Gupreet Kaur (Wife)] [Mahinder Singh (Son)] -- [Mandeep Kaur (Daughter-in-law)] [Sardeep Kaur (Grand Daughter)]