Professional Documents
Culture Documents
Sureshbhai Heenaben
Mention each symbol description:
: Male
: Female
: Female Patient
Family composion
Name of family member Age/sex Relation with patient Health status
5) Personal history:
• Diet : Veg and Non- veg
• Sleep/rest : Sleep pattern disturb due to Pain
• Micturation : Normal
• Bad habits : No any bad habits.
6) Socio-economic history:
They belongs to middle class family because the monthly income is 10000 Rs per month.
Relationship with the family member is good also with the other family member and societal
member.
PHYSICAL EXAMINATION
VITAL SIGN:
TEMPERATURE : 98.6F
PULSE : 76 B/ MINUTE
RESPIRATION : 22/MINUTE
BLOOD PRESSURE : 110/70MM HG
GENERAL APPERANCE:
• Body image : Thin
• Health : Unhealthy
• Activity : Dull
MENTAL STATUS:
• Consciousness : Conscious
• Look : Anxious
POSTURE:
• Body curves : No any kyphosis, lordosis
• Movement : Normal
SKIN CONDITION:
• Color : no any cyanosis
• Texture : No any wrinkles
• Temperature : Normal
• Lesions : No any lesions are present
HEAD & FACE:
• Scalp : No any scar, dandruff present
• Face : No any edema, anxious look
EYES:
• Eyebrow : No any dandruff present
• Eye lashes : No any infection present
• Eyelids : No any discharge present
• Eye balls : Both eyes coordinated
• Conjunctiva : No any redness
• Sclera : No any jaundice
• Pupils : Reactive to light
• Vision : Normal
EAR:
• External ear : No any discharge from external ear
• Hearing : Normal
NOSE:
• External nares : No any discharge from external nose
• Nostrils : No any nasal septum deviation
LFT
SR. BILIRUBIN LEVEL 2.0mg/dl 0.2-1.0mg%
DIRECT 0.6mg/dl 0-0.3mg%
SGOT 12 5-40IU/L
RFT
SERUM
ELECTROLYTE 121Meq/l 135-145meq/l
Sr. SODIUM 2.6Meq/l 3.5-5.5 meq/l
SR. POTASSIUM
URINE ROUTINE
NORMAL