سعد احمد ضايف.م.م ماجستير تمريض البالغين college of nursing university of Thi-Qar Case sheet history Identity (demographic details) Name: Age: Sex: Occupation: Address: Religion: Marital status: Next of kin: Date of admission: Blood group: Example of an identity: Mohamed Ali Ahmed is seventy years old; he is a male. He is a teacher living in ThiQar/Al-Nasiriya. He is a Muslim, married and had three daughters and two sons. His next of kin is Ahmed Ali; his brother. The patient is admitted into the hospital on sixteenth of January 2023. His blood group is AB positive. Chief compliant & duration: - Use patient's own wording and not medically correct terms Example: • Diarrhea = frequent bowel motion for one day before admission to the hospital. • Constipation = infrequent bowel motion for two days before admission to the hospital. • Vomiting = explosion of gastric content for one day before admission to the hospital or (same term). • Fever = elevated body temperature for one day before admission to the hospital. • Dysphagia = difficulty in swallowing for two days before admission to the hospital. 1 سعد احمد ضايف.م.م ماجستير تمريض البالغين • Dyspnea = shortness of breath for five days before admission to the hospital. • Fit = abnormal involuntary movement for one day before admission to the hospital. • Headache = same term for one day before admission to the hospital. • Pain = same term for one day before admission to the hospital. • Edema = swelling of part of the body for one day before admission to the hospital. • Jaundice = yellow discoloration of the skin & sclera for one day before admission to the hospital. • Hematemesis = blood on vomitus for one day before admission to the hospital. • Hemoptysis = blood in sputum for one day before admission to the hospital. • Cyanosis = bluish discoloration of the skin & sclera for one day before admission to the hospital. • Weakness = same term for one day before admission to the hospital. • Coma = Loss of consciousness for one day before admission to the hospital. • Palpitation= Awareness of heart beats for one day before admission to the hospital. • Retention= Inability to pass urine for one day before admission to the hospital. • Heart burn =Burning sensation in the chest for one day before admission to the hospital. • Fatigue =Generalized weakness of the body for one day before admission to the hospital. History of present illness: How to start the present illness? In two ways: 1) If the patient has a chronic condition previously such as (diabetes, or hypertension …) write as the patient is a known case of …… for duration presented with …... 2) The condition started when the patient (suddenly or gradually) complained of …… what are the questions to ask? ❖ Pain - Site. 2 سعد احمد ضايف.م.م ماجستير تمريض البالغين − Continuous or intermittent? − Localized or diffused? − Radiation. − Intensity (severe, moderate, mild). − Character (stabbing, colicky, dull, sharping, heaviness, burning…). − Aggravating factors. − Relief factors. − Associated symptoms. − Action of patient. − Condition of patient ❖ Fever _ Sudden or gradual? − Severity of fever. − Frequency. − Aggravating factors. − Relief factors. − Associated with chills? − Action of patient. − Condition of patient. ❖ Diarrhea - Sudden or gradual? − Continuous or intermittent? − Color, quantity, order, content. − Is the diarrhea accompanied with mucous or blood? − Associated with other symptom (loss of weight, fever, vomiting, abdominal pain). − Aggravating factors. − Relief factors. − Action of patient. − Condition of patient. ❖ Vomiting - Sudden or gradual? − Forceful or projectile (meningitis)? − Any special time of vomiting. − What is the amount, smell, color & content of vomitus? − Aggravating factors. 3 سعد احمد ضايف.م.م ماجستير تمريض البالغين − Relief factors. − Action of patient. − Condition of patient. ❖ Cough - Sudden or gradual? − Severity − Frequency? − Any special time for cough? − Aggravating factors (dust, pollen). − Dry or productive? if productive: the amount, character, color, smell of sputum? is there any blood in sputum? fresh, red, dark brown, mixed with sputum or in a form of streak? − Action of patient. − Condition of patient. * Type of sputum: Type Appearance Serous Mucoid Clear, watery, frothy, pink Acute pulmonary edema , alveolar cell cancer Clear , grey , white , viscid Chronic bronchitis / COPD asthma Purulent Yellow , green Pneumonia , lung abscess Rusty Rusty , golden , yellow Pneumococcal , pneumonia ❖ Headache Cause - Sudden or gradual? − Severity − Frequency? − Character of pain (dull, throbbing & shooting). − Continuous or intermittent? − Aggravating & relief factors? − Site of the pain. − Associated symptoms. − Action of patient. − Condition of patient. 4 ❖ Weakness سعد احمد ضايف.م.م ماجستير تمريض البالغين - Sudden or gradual? if gradual; what is the duration − Generalized or localized? what is the part if localized? − Grade of weakness. − Associated symptoms: loss of consciousness, fever, loss of sensation. − Aggravating & relief factors? − Site of the weakness. − Associated symptoms. − Action of patient. − Condition of patient. Example of the history of present illness: The condition starts as sudden colic pain on right iliac area and sever continuous daily, radiated to umbilically and then to back, the pain increase over exertion and walking and relive by rest and when taken of treatment, the conditions associated with vomiting and nausea. The patient firstly visits the dr. in privet clinic, the dr. performs physical examination and referral to lab and diagnostic test (ultrasound, Chest x-ray, blood test). The dr. diagnoses the patient with suspected appendices, referral to emergency department and to prepare the patient for appendectomy, the patient now under fellow up. System of review: 1. Exclude the system that is involved in present illness. 2. You can use medical terms. A. Cardiovascular system Question about it: − Chest pain ــDyspnea ــEdema − Palpitation What bring it? Duration − Epistaxis bleeding under the skin − Claudication pain in calf muscle in walking Pulse B. Central nervous system Question about it: − Paralysis ــheadache ــblurred vision ــdiplopia − Convulsion associated with loss of consciousness − Any abnormal movement 5 سعد احمد ضايف.م.م ماجستير تمريض البالغين − Vertigo continuous or paroxysmal? severity − Control of the sphincters , muscle weakness C. Respiratory system Question about it: − Cough what it's characters − sputum what it's characters − palpitation & leg swelling − dyspnea − chest pain D. Urogenital system Question about it: − urine volume: (polyuria, oliguria, retention, anuria, dysuria) − frequency , incontinence & urgency − nocturia : as in D.M , renal failure or UTI − hematuria with pain or not − burring micturition − loin pain & it's radiation E. Gastrointestinal system Question about it: − Appetite − Nausea − Vomiting & it's characteristic − Dysphagia : Type of food − Salivation − Heart burn − Thirst − Abdominal pain − Abdominal distension − Diarrhea − Constipation − Melaena : dark stool of indigested food − Hematochezia: fresh blood in stool − Use of laxative − Acidity 6 سعد احمد ضايف.م.م ماجستير تمريض البالغين − Hematemesis − Tenesmus: pain in defecation − Flatulence F. Locomotor system Question about it: − Arthralgia :whish joint − Myalgia & bone ache − Disturbance of gait − Deformity or any abnormality of skeletal system − Joint swelling G. Integumentary system Question about it: − Rash: duration & associated with pain? − Hyperpigmentation − Loss of hair & skin pigmentation − Hair over growth − Family history of skin disease Past history: 1. Medical history This part includes the chronic disease …………. The patient is a known case: - diabetes mellitus, hypertension, ulcer, T.B, asthma, any previous hospitalization 2. Surgical history Any operation in the past. Drug history: Write if the patient on therapy 7 سعد احمد ضايف.م.م ماجستير تمريض البالغين 1) Antibiotic 2) Radiotherapy 3) Allergy to penicillin , aspirin , sulph drug 4) Psychotropic drug 5) Blood transfusion 6) Vaccination 7) Steroid Family history: Question about it: 1) No. of sister, brother , daughter , sons & there health . 2) Are the parent alive or not ? Are they relatives or not ? 3) Any familiar disease . Personal & social history: Question about it :1) Smoker or not ? 2) Alcoholic or not ? 3) Any special habit ( bird collector ) . 4) Economic & nutritional state . 5) Living in large or small place ? 6) Water supplementation ( tab , river water )? 7) In rural urban place . 8) Is there any domestic animal ? 9) Level of education . 10) Martial state . 8
