IDENTIFICATION DATA

NAME OF PATIENT- mr. manohar singh

SEX- male
AGE- 45 yrs
WARD- medical male ward
DATE OF ADMISSION- 13/1 /2015
EDUCATION 8th passed
RELIGION- hindu
MARITAL STATUS- married
OCCUPATION- labour
ADDRESSDIAGNOSIS- liver of cirrohsis- alcoholic
DATE OF SURGERY- n/a
OPERATION- n/a
DATE OF DISCHARGE-n/a
PRESENT COMPLAIN+

SOCIO ECONOMIC STATUSFAMILY HISTORY

S.
NO
.

NAME OF FAMILY
MEMBER

AGE/S
EX

FAMILY TREEILLNESS HISTORY

PRESENT MEDICAL HISTORY

PRESENT SURGICAL HISTORY
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY

PERSONAL HISTORY

PERSONAL HYGIENE
DIETARY
SLEEP
ELIMINATION
ACTIVITY & EXERCISE

RELATION
WITH PATIENT

OCCUPATION

MEDICAL
HISTORY

JOINT
HABITS
ALLERGY
IMMUNISATION STATUS

PHYSICAL EXAMINATION

GENERAL APPEARANCE
HEIGHT AND WEIGHT
VITALS
S.N
O
1
2
3
4

VITAL SIGNS

PATIENTS
VALUE

TEMPERATURE
PULSE
RESPIRATION
BLOOD
PRESSURE

HEAD
SCALP
HAIR
EYE
EYELID
EYE BROW
DISCHARGE
EAR
HEARING ABILITY
DISCHARGE
NOSE
NASAL SEPTUM
DISCHARGE
NECK
ALIGNMENT
MOVEMENT
LYMPH NODE
RESPIRATORY SYSTEM
RESPIRATORY RATE
RESPIRATORY DISTRESS
CARDIOVASCULAR SYSTEM
APICAL PULSE RATE
ABDOMEN
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
MUSCULO-SKELETAL SYSTEM

NORMAL VALUE
98.60 F
70-80 beats/min
16-24 breath/min
120/80 mm Hg

REMARK

NERVOUS SYSTEM

INVESTIGATION