Patient Admission For Cardiovascular

System
1st Group

Undergraduate Nursing Program

Faculty of Nursing
Andalas University
2015

Medical Record :
Patient Name
:
Date of Birth
:
Address
:
Gender
:
Male
Age
:
Religion
:
Mothers Name :
Phone
:
Admit Date
:

Female

Reason Patient Admission

Have you been hospitalized in 3 months ?
Reason :

Yes
No
How Long :

Reason for this admission and History or Presenting Illness :

If reason for admission is the result of an accident, please state :
When injury occured :
How injury occured :
How injury occured :
General Medical History
General Medical History

Yes

No
(Please Tick)

Family history about cardiac disease

Heart disease including Heart Attack / Angina
High Blood Presure
Weight and Height
High Cholesterol
(Please Circle) Peripheral Vascular Disease Palpitation,
Irregular Heart Beat/Heart Murmur
Implanted Device Pacemaker
(Please Circle) Asthma / Bronchitis / Emphysema / shortness
of breath / Pneumonia / TB
Anasthetic Reaction
Diabetes Type 1 Type 2
(Please Circle) Blood Disorder / Bleeding Problems / Anemia
Infectious Disease : HIV / Sexual / Hepatitis / other
infections
Skin Condition Wound / ulcers / broken skin

Weight :

Height :

Case :
Mrs Princess Barbie is a 63-year old woman who has been medical problems during the past 5 years. He has been
treated for two myocardial infarctions, hypertension, non-insulin dependent diabetes and stasis dermatitis of the
left leg. He had an aorto-coronary bypass one year ago. Her family history have a cardiac disease too.
Today he presents in the office with shortness of breath which has been progressive over the past five days. He
has, however, experienced episodes of shortness of breath during the past four months, especially when exerting
himself. He fatigues easily and has lost "all my energy to do anything." He also complains of anorexia. Last night he
awoke suddenly from sleep because "I couldnt catch my breath" and developed a dry cough. The breathing
problem improved when he sat on the edge of his bed for an hour. He generally sleeps with two, sometimes three
pillows. He has experienced chest pain, leg pain or fainting spells.
She appears depressed and older than her stated age. He is unkept and unshaven. Her shoes are untied. Her
breathing is labored and his lips have a blue tinge. Vital Signs: Blood Pressure 98/82mmHg in the right arm; Heart
Rate 110/min; Respiratory Rate 26/min; Temperature 98 F. Examination of the lungs reveals dullness to percussion
in both bases with decreased excursion of the diaphragms. Course rhonchi and moist, inspiratory crackles are
heard bilaterally in the lower lung fields. Examination of the cardiovascular system: Neck veins are prominent and
distended to the mandible when the patient is sitting upright. The apical pulse is palpated in the 5ICS, left of the
MCL. S3 is palpable at the apex. S1 and S2 are diminished. S3 is heard at the apex. A grade 3/6 holosytolic murmur
is heard best at the apex; it radiated to the left axilla.
The patient is hospitalized.