PATIENT PROFILE

Name of client : Mrs. Chandrika

Age : 32 years

Sex : Female

I P No. : 21485

Ward : Female Medical Ward

Unit : II Unit

Marital Status : Married

Educational Qualification : 5th std

Religion : Hindu

Occupation : Cooly

Income : Rs.900 per month

Address : Pillayar koil street,

Viruthunagar District

Admitted on : 21.03.2017

Source of data : patient, patient wife & case sheet

Diagnosis : Chronic Obstructive Pulmonary

Disease
Present Medical History

C.O.L.D.S.P.A

Character : Describe signs and symptoms

Onset : When did it begins

Location : Where it radiates

Duration : How long does it lost?

Severity : How bad it is

Pattern : What makes better what makes it worse?

Associated factors: What other symptoms occurs with it.

Describe about chest pain - Pain/No Pain

When it starts / Type of Pain /

Rate the pain on pain scale

Perspiration / Palpitation / tiredness / Fatigue

Dyspnea : shortness of breath/ orthopnoea

Visual Analogue Scale

Shortness of breath 100mm

No shortness of breath

Subjective symptom:

On a scale 0 – 4

No distress 0 1 2 3 4

Much distress 0 1 2 3 4

Poor appetite 0 1 2 3 4
Worn out 0 1 2 3 4

Suffocation 0 1 2 3 4

Tightness 0 1 2 3 4

Congestion 0 1 2 3 4

A feeling of panic 0 1 2 3 4

New York Heart Association Classification

0 - Not at all breathless

1 - Breathless on heavy exercise (climbing 2 or 3 floors or waling quickly)
2 - Breathless on moderate excursion
3 - Breathless on mild excursion
4 - Breathless on minimal excursion
5 - Breathless on minimal excursion

Past Health History:

Heart defect / mummer / Rheumatic heart disease / Previous history of cardiac

surgery / intervention previous ECG / Blood test lipid profile / previous
history of medication

Family History:

Family History of Hypertension / Myocardial infarction / coronary heart

disease / elevated cholesterol level / Diabetes.

Life style and health care practices:

 Smoking history
 Packs per day
 Years of smoking
 Coping of stress mechanism
 Alcohol consumption in a day / week
 Exercise type of excessive
 Describe the daily activity / change in the past 5 – 10 years / limitation in the
performance of daily activity.
 History of sexual activity
 Number of pillows used for sleep Nocturnal
 Anxiety regarding heart disease
 Importance of having healthy heart
 HEAD TO FOOT ASSESSMENT

General appearance : Thin / Moderate built / obese

Height : in cm

Weight : in kg

Head

Face : Symmetrical / Asymmetrical

Edema : Present / Absent

Eye :

Eye brow : Equal distribution of hair/

Sparingly distributed /

Absent

Eye lashes : Equal distribution of hair/

Sparingly distributed /

Absent

Conjunctiva : Pale / yellow / pink / per orbital cyanosis

Eye lids : Able to open & close / ptosis

Pupils : PERLA

Eye

Position : Above the level of outer cantus /

At the level of outer canthus /

Below the level of outer canthus

Drainage : Present / Absent

Nostrils : Patent / Obstructed

Septum : Centre / deviated

Discharge : present / absent

Mouth

Lips : Dry / Moist / cyanosis

Gums : Health / Swollen / gingivitis

Odour : Present / Absent

Throat : Normal / inflamed

Neck

Trachea : Midline / deviated

Retraction : Present / Absent

Upper Extremity

ROM : Full / Limited

Abdomen

Inspection : Shape / Scar / Lesion

Auscultation : Bowel sound / Present /

Absent / Borborgymi

Percussion : Tymphony / resonant / dull

Palpation : Organomegali / tenderness

Lower Extremity

ROM : Full / limited

Capillary refill: <3 seconds / >3 seconds

Genitalia

External : Drainage / edemaInflammation / odour

 REVIEW OF SYSTEM

Preparing the patient for cardiac assessment

Explain and expose only the area to be evaluated.

Wear examination gown. Explain procedure.

Equipments:

 Stethoscope
 Small pillow
 Penlight or movable examination light
 Watch
 Centimeter ruler – 2
 Centimeter tape
 Stethoscope
 Tourniquet
 Gauze or tissue
 Water proof pen
 Blood pressure cuff

Cardiac land mark:

1. Aortic area
2. Pulmonic area
3. Mid pericardial area
4. Tricuspid area
5. Mitral area

Carotid inspection:

Pulsation / Cardiac land mark

Palpation:

For pulsation / thrills / Leaves

Auscultation:

Auscultate carotid artery –

No blowing / Swising / or other sound

Pulse equality or unequal

Pulse amplitude sound

0 = absent

1+ = weak

2+ = normal

3+ = increased

4+ = bounding

Auscultate pericardium

At the apex / sinus arrhythmia

Bradycardia - < 60 beats / minute

Tachycardia - > 100 beats / minute

Premature ventricular contraction / Arterial fibrillation / arterial flutter. Pulse rate

deficit.

S1 - lub - loudest at the apex

S2 - dub - loudest at the base

Accentuated / diminished / varying / split sound

Extra sounds:

Ejections sound / click /

S3 - physiologic / pathologic

S4 - physiologic / pathologic

Mummers:

 Innocent physiologic mid systolic murmur /

  Pathologic midsystolic / pan systolic / diastolic mummer

 Auscultation on change of position

HISTORY OF PRESENT HEALTH CONCERN

USE C.O.L.D.S.P.A

Character :

Onset :

Location :

Duration :

Severity :

Pattern :

Associated factors :

Present Medical History

 Change in color, temperature, or texture change in skin.

 Pain or cramping pain (aching / stabbing)
 How often
 Wake up from sleep
 Leg veins ropelike, bulging, contorted
 Any sores or open wounds, Location and pain
 Any swelling legs or feet. Time of swelling worst. Pain with swelling.
 Swollen glands or lymph nodes. Tender, soft or hard.
 Sex history.

Past Medical History

 Problems in the circulation of arms and legs.

 Any heart blood vessel surgeries or treatment.

Family History
 Family history of diabetes / hypertension / coronary heart disease / elevated
triglyceride levels.

Life style and health practices

 Smoking
 Pack per day
 Year of smoking
 History of exercise FITT
 Use of transdermal contraceptives.
 Describe the degree of stress
 Problems with circulation
 Leg ulcers, varicose veins – feeling about
 Medication history
 Support hose

APMS:

Physical assessment:

Inspection

 Observe arm size and venous pattern look for edema.

Bilaterally equal / No edema. Lymph edema
 Observe coloration of the hands and arms-
Bilateral coloration symmetrical. Pallar, cyanosis, redness.

Palpation

 Finger hands - Temperature – warm / cool

 Capillary refill time - 1- 2 seconds

>2 seconds.

 Radial pulse - 2+ /Increased / bounding / diminished

 Ulnar pulses - not deductable / inelastic
 Brachial pulses - equal / strength / symmetric
 lymph Node - not palpable / palpable
 Allens test - coloration 3-5 seconds / > 5 seconds / pale

LEGS
Color - pink / brown / pallor / Rubor cyanosis /

rusty brownies pigmentation

Distribution
Of hair - even distribution / loss of hair

Lesion or ulcers - free of ulcer / ulcer with smooth

Ulcer with irregular edges
Edema

 1+ - slight pitting
 2+ - deeper than 1+
 3+ - deep + extremity looks larger
 4+ - very deep gross edema extremity
 Bilateral / Unilateral

Temperature of the feet and legs

Warm / coolness / increased temperature

Superficial inguinal lymph nodes

Non tender / lymph node larger than 2 cm /

Femoral pulses : strong / equal / weak /

Auscultation : No sound / bruits /

Popliteal pulses : Palpable / not palpable /

Dorsalis pedis : Bilateral / weak / absent /

Posteriortibial pulses : Present / Bilateral / weak / absent /

Varicosities &
Thrompophlebitis : No varicosity / varicose veins / bulging /
Nodular /

Homan’s sign : Negative / Positive /

Special Test for aterial venous insufficiency

Position change
Test : pink / light pale / pallor coloration > 15 seconds

Trendlenberg
Test : Fill from below / fill from above

CENTRAL NERVOUS SYSTEM:

Level of consciousness : Alert and awake/ Letharg/Obtunded/Stupor/Coma.

Dress and Grooming : Neat/ Meticulous grooming.

Facial expression : Good eye contact/ Poor eye contact.

Speech : Moderate tone/ Slow / Repetitive.

Head ache : Present Absent.

RESPIRATORY SYSTEM:

Symmetry of chest wall : Symmetrical / Asymmetrical.

Rate/ Rhythm/Pattern : Resonant/ Hyper resonant.

INTEGUMENTARY SYSTEM:

Color of the skin : White skins/Darker skins/ Pallor/ Cyanosis.

Skin capillary refill : Pink tone return immediately,

/ < 3 seconds >3 Seconds.

Distribution of hair : Hair covers the scalp/ Hair loss.

MUSCULO SKELETAL SYSTEM:

Gait : Posture erect/ UN even weight bearing.

ROM : Full ROM against resistance/ Pain / Spasms

Swelling : No bulge/ Bulge of fluid.

Size / Shape / Deformities : Symmetric without deformities/ Redness/ heat/

Swelling / Deformities.

Muscle strength : Complete absence of contraction (0)/ Normal

Strength (5)/ (Scale 0 – 5)

GENITO URINARY SYSTEM:

Urethral discharge : Free of discharge/ a yellow discharge.

Inguinal hernia : Bulging or mass not seen/ A bulge or mass seen

VITAL SIGN:

Temperature :

Pulse :

Respiration :

B.P :

Pain scale : Numerical pain scale

0 1 2 3 4 5 6 7 8 9 10

NUTRITIONAL ASSESSMENT
 A. Diet history

- Ask about a history of nausea, vomiting and abdominal pain

- Ask about increase or decrease in food or fluid intake

Excessive thirst : (present in Diabetes insipidus)

Salt craving : (present in Adrenal hypo function)

Increase in hunger & thirst : (present Diabetes mellitus)

Rapid change in weight : Diabetes mellitus / Thyroid problems

B. ANTHROPOMETRIC MEASUREMENTS

Height : in cm

Weight : in kg

BMI : Weight in Kg

M2

Normal limits : 20 – 25

Overweight : 25 - 29.9

Obese (class I) : 30 – 34.9

Moderately obese (class II) : 35 – 39.9

Extremely obese (class III) : > 40

Ideal body weight : Current weight

--------------------- X 100
 Ideal body weight

Mild obesity : 20 – 40 %

Moderate obesity : 40 – 100 %

Morbid obesity : > 100%

Waist Hip Ratio : Waist in inches Female : 0.8

(normal)

Hip in inches Male :1

(normal)