Biographical data

Name: Patient x Religion: N/A

Age: 26 years old Dialect/Language Spoken: English

Gender: Female Nationality: N/A

Civil Status: Married

Address: N/A Informant (For Pediatrics or secondary source of

information)
Date of Birth: N/A
Date of Admission: April 19,2021
Place of Birth: N/A
Date of Discharge:

Admitting Diagnosis/ Impression

Educational Attainment: N/A
Final Diagnosis: Rheumatic Heart Disease
Occupation: N/A

Nursing History
CHIEF COMPLAINT V:

The patient admitted in antenatal ward with the complaints of breathlessness, palpitation, fatigue,
weakness, and bilateral pitting edema for 2 months duration.

HISTORY OF PRESENT ILLNES:

- 2 days prior to the admission the patient in that the findings were severe MR with dilated
left atrium and pulmonary hypertension
PAST MEDICAL HISTORY:

The patient had a history of RHD disease with severe mitral regurgitation in the age of 14 years

She had rheumatic fever with sore throat in childhood, later she developed RHD.

FAMILY MEDICAL HISTORY with GENOGRAM:

N/A
PERSONAL/SOCIAL/ENVIRONMENTAL HISTORY:

N/A

OBSTETRIC/GYNECOLOGICAL HISTORY:

Primigravida woman with 38 5/7 weeks of gestation

She delivered an alive male neonate with the birth weight of 2.01 kg. APGAR score was 7/10 at
1 minute and 8/10 at 5 minutes.