SAMPLE HISTORY COLLECTION BY A STUDENT NURSE.pptx

“I was posted in the medical ward at ……….. Hospital, Shimoga, on 12/09/24. During my posting, I came across Mr. Ramesh, a 75-year-old male, who presented with chief complaints of nasal congestion, frequent sneezing, and a runny nose for the past two weeks. After undergoing all the necessary diagnostic procedures, Dr. X diagnosed him with rhinitis. He is currently under treatment by Dr. X.”
Full Name: Mr. Ramesh Kumar
Age: 75 years
Gender: Male
Date of Birth: January 1, 1949
Marital Status: Married
Education: Bachelor’s degree
Occupation: Retired school teacher
Name of the informant :
Name: Mrs. Sita Ramesh (Wife)
Relationship: Spouse
Contact Information:
Phone Number: …………………………..
Address: MG Road, Shimoga, Karnataka, India
Email: [email protected]
Additional Details for Hospital Admission
IP Number: 123456
Admission Date: September 12, 2024
Hospital: ------ Hospital, Shimoga
Ward: Medical Ward
Room Number: 305
Attending Physician: Dr. X
Reason for Admission: Acute rhinitis with symptoms of nasal congestion, frequent sneezing, and a runny nose for the past two weeks.
Diagnosis: Rhinitis
Discharge Details
Date of Discharge: September 20, 2024
Discharge Care Started: September 20, 2024
Discharge Care Ended: Ongoing (or specify an end date if applicable)
“Mr. Ramesh, a 75-year-old male, presented with nasal congestion, frequent sneezing, and a runny nose for the past two weeks. These symptoms have persisted despite over-the-counter medications, and he also reported mild headaches and fatigue. Upon examination, his nasal mucosa was swollen with clear nasal discharge, leading to a diagnosis of acute rhinitis by Dr. X.”
Mr. Ramesh, a 75-year-old male, was admitted at ………..hospital, Shimoga on September 12, 2024.He
has been experiencing nasal congestion, frequent sneezing, and a runny nose for the past two weeks. Despite using over-the-counter antihistamines, his symptoms have persisted. He also reports mild headaches and fatigue. Upon examination and diagnostic tests, Dr. X diagnosed him with acute rhinitis. He is currently being treated with prescribed antihistamines and nasal decongestants, with follow-up care planned.
Mr. Ramesh, a 75-year-old male, has a significant past medical history. In 2012, he was admitted to …………..government Hospital, shimoga for one week due to pneumonia. During this time, he received appropriate treatment and recovered fully. There are no other notable past medical conditions reported.
Mr. Ramesh, a 75-year-old male, has no recent surgical history. He has no current surgical interventions planned. His medical management is focused on treating his acute rhinitis and monitoring his overall health.
Mr. Ramesh, a 75-year-old male, underwent Herniorrhaphy surgery in January 2020 at ………….. Hospital. He was hospitalized for seven days following the procedure and recovered without any complications. There are no other significant surgical interventions reported in his history. etc..

1. A SAMPLE HISTORY COLLECTION BY A STUDENT NURSE. Patient :Mr. Ramesh Diagnosis: Rhinitis MRS.WINCY THIRUMURUGAN PROFESSOR

2. INTRODUCTION “I was posted in the medical ward at ……….. Hospital, Shimoga, on 12/09/24. During my posting, I came across Mr. Ramesh, a 75-year-old male, who presented with chief complaints of nasal congestion, frequent sneezing, and a runny nose for the past two weeks. After undergoing all the necessary diagnostic procedures, Dr. X diagnosed him with rhinitis. He is currently under treatment by Dr. X.”

3. Personal Information/Patient ‘s profile Full Name : Mr. Ramesh Kumar Age : 75 years Gender : Male Date of Birth : January 1, 1949 Marital Status : Married Education: Bachelor’s degree Occupation : Retired school teacher Name of the informant : Name : Mrs. Sita Ramesh (Wife) Relationship : Spouse Contact Information : Phone Number : ………………………….. Address : MG Road, Shimoga, Karnataka, India Email : [email protected]

4. Additional Details for Hospital Admission IP Number : 123456 Admission Date : September 12, 2024 Hospital : ------ Hospital, Shimoga Ward : Medical Ward Room Number : 305 Attending Physician : Dr. X Reason for Admission : Acute rhinitis with symptoms of nasal congestion, frequent sneezing, and a runny nose for the past two weeks. Diagnosis: Rhinitis Discharge Details Date of Discharge : September 20, 2024 Discharge Care Started : September 20, 2024 Discharge Care Ended : Ongoing (or specify an end date if applicable)

5. CHIEF COMPLAINTS “Mr. Ramesh, a 75-year-old male, presented with nasal congestion, frequent sneezing, and a runny nose for the past two weeks. These symptoms have persisted despite over-the-counter medications, and he also reported mild headaches and fatigue. Upon examination, his nasal mucosa was swollen with clear nasal discharge, leading to a diagnosis of acute rhinitis by Dr. X.”

6. Present Medical History Mr. Ramesh, a 75-year-old male, was admitted at ………..hospital, Shimoga on September 12, 2024.He has been experiencing nasal congestion, frequent sneezing, and a runny nose for the past two weeks. Despite using over-the-counter antihistamines, his symptoms have persisted. He also reports mild headaches and fatigue. Upon examination and diagnostic tests, Dr. X diagnosed him with acute rhinitis. He is currently being treated with prescribed antihistamines and nasal decongestants, with follow-up care planned.

7. Past Medical History Mr. Ramesh, a 75-year-old male, has a significant past medical history. In 2012, he was admitted to …………..government Hospital, shimoga for one week due to pneumonia. During this time, he received appropriate treatment and recovered fully. There are no other notable past medical conditions reported.

8. Present Surgical History Mr. Ramesh, a 75-year-old male, has no recent surgical history. He has no current surgical interventions planned. His medical management is focused on treating his acute rhinitis and monitoring his overall health.

9. Past Surgical History Mr. Ramesh, a 75-year-old male, underwent Herniorrhaphy surgery in January 2020 at ………….. Hospital. He was hospitalized for seven days following the procedure and recovered without any complications. There are no other significant surgical interventions reported in his history.

10. FAMILY HISTORY

11. Mr. Ramesh, patient, 75-year Mrs. Seetha, ,wife. 63 years old Mr. Gopal,son , 42 years Mrs. Sumathi, Daughter in law, 40 years Mr. Tharun , grandson, 20 years Mr. Thilak , grandson,18years FAMILY TREE /PEDIGREE CHART

12. Family Medical History Mr. Ramesh, a 75-year-old male, comes from a middle-class, urban family consisting of five members. There are no significant hereditary or communicable diseases reported in the family history. The family lives together in a supportive environment, and all members are generally in good health.

13. Socio-Economic History Mr. Ramesh, a 75-year-old male, belongs to a middle-class family with a monthly income of ₹20,000. He is the primary breadwinner of the family. They own a house in an urban area, which is well-equipped with essential amenities. The household has access to good quality water, an efficient garbage disposal system, and a closed drainage system. The electricity supply is reliable, and they purchase food from a nearby market. The area around their home is free from flies, and there is no soil, air, or water pollution, contributing to a healthy living environment.

14. Personal History Mr. Ramesh, a 75-year-old male, has a moderate body build and maintains a healthy lifestyle. He has no habits of smoking and consuming other tobacco products and only occasionally drinks alcohol. His diet consists of a mix of different food types, and he engages in regular exercise. He has three meals a day and no addictions. His bowel and bladder habits are regular, and he enjoys 8-10 hours of sleep each night. Mr. Ramesh is sociable and enjoys mingling and socializing with others