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    This case study summarizes information about a 26-year old male patient named Neeraj Sharma who was admitted to the ICU on August 25, 2017 with a diagnosis of respiratory distress syndrome. The patient presented with chest pain, insomnia, dry mouth, and restless sleep. He has no significant past medical or surgical history. A family history assessment found that the patient comes from a family of 4 people with a total monthly income of 90,000 rupees. A physical exam found abnormal vital signs including low blood pressure, oxygen saturation, and elevated temperature and pulse. The patient is recommended for coronary artery surgery.

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    CASE STUDY 1 uday rdh

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    This case study summarizes information about a 26-year old male patient named Neeraj Sharma who was admitted to the ICU on August 25, 2017 with a diagnosis of respiratory distress syndrome. The patient presented with chest pain, insomnia, dry mouth, and restless sleep. He has no significant past medical or surgical history. A family history assessment found that the patient comes from a family of 4 people with a total monthly income of 90,000 rupees. A physical exam found abnormal vital signs including low blood pressure, oxygen saturation, and elevated temperature and pulse. The patient is recommended for coronary artery surgery.

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    49 views6 pages

    CASE STUDY 1 Uday RDH

    Uploaded by

    New Whatsapp Status Video
    This case study summarizes information about a 26-year old male patient named Neeraj Sharma who was admitted to the ICU on August 25, 2017 with a diagnosis of respiratory distress syndrome. The patient presented with chest pain, insomnia, dry mouth, and restless sleep. He has no significant past medical or surgical history. A family history assessment found that the patient comes from a family of 4 people with a total monthly income of 90,000 rupees. A physical exam found abnormal vital signs including low blood pressure, oxygen saturation, and elevated temperature and pulse. The patient is recommended for coronary artery surgery.

    Copyright:

    © All Rights Reserved
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    of 6

    CASE STUDY

    PATIENT BIODATA
    1. NAME = Neeraj Sharma
    2. AGE = 26yrs
    3. SEX = Male
    4. BIRTHDAY = 08nov 1991
    5. FATHER NAME = Manoj sharma
    6. RELIGION = Hindu
    7. CIVIL STSTUS = Unmarried
    8. ADDRESS = Meena colony ,dausa,
    (rajasthan)
    9. OCCUPATIONAL = Student
    10. STATE = Rajasthan

    11. DATE OF ADMISSION = 25Aug 2017

    12. TIME OF ADMISSION = 10:00PM

    13. BLOOD GROUP = A negative

    14. ATTENDING DOCTOR = Dr.sujal gupta

    15. Reg. NO. = 362016226155

    16. IPD. NO. = 360301564900


    17. DEPARTMENT =
    18. WARD = ICU

    19. BED NO. = 04

    20. ADMITTING DIAGNOSIS = RDH

    MADICAL HISTORY

    1) CHIF COMPLAINTS 
    I. Pt. having severe chestpain
    II. Pt. Having insomnia .
    III. Pt .having xerostomia.
    IV. Pt .having disturb sleeping pattern.

    2) PRESENT ILLNESS
    I. Chest pain
    II. insomnia
    III. Dryness of mouth
    IV. Restless sleep.

    3) PAST ILLNESS
    I. Pt .was difficulty in hard works.
    II. Pt .was suffered with pain.
    III. Pt .was suffered with common cold .

    SURGICAL HISTORY

    1. PRESENT SURGERY
    The doctor must be advice the pt.for
    following surgery.
    I. Coronary artery surgery

    2. PAST SURGERY
    The pt. has not any past surgery

    FAMILY HISTORY

    1. No. OF FAMILY MEMBERS = 4


    2. TOTAL INCOME OF FAMILY = 90,000rs

    S.R NAME AGE/S RELATIO EDU. OCCU. INCOME HEALTH


    . EX N STATUS
    No.

    1 Manoj 55Y/M Father 10th Offset 30,000rs Healthy


    2 Rinku 50Y/F mother 10th Healthy
    devi
    3 Neeraj 26Y/M Self M.Sc. Private 40,000 Un
    (N) employ Healthy
    e
    4 Hari 22yrs/ Brother B.Sc. Private 20.000 Health
    mohan M employ
    e
    FAMILY TREE

    Manoj Rinku Devi50 Y/F


    55 YRS/MALE

    Rohit Hari mohan 22 yrs/m


    26yrs/male
     SOCIAL HISTORY=
    The pt. is not well living in the society & not more wellness in social
    in nature .

     ECONOMICAL HISTORY =
    Economic condition of the pt. and his

    family is well

     NUTRITIONAL HISTORY =
    The pt. & his family is well nourished

    A.ENVIROMENTAL HISTORY =

    S.R NAME STATUS


    .
     No.
    1 Air Fresh
    2 Water Safe
    3 Food Safe

    OCCUPATIONAL HISTORY =
    Pt. is complete education and work as a private employe .

     PERSONAL HISTORY =
    i.EATTING HABIT =Well (veg)
    ii.SLEEPING HABIT = disturb sleeping
    pattern
    iii.SMOKING = no
    iv.ALCOHOLISM = no
     Vital signs:-
    NORMAL VALUE RECORDED VALUE

    Bp 120/80 Bpm 90/70bpm


    O2 sat 95% 76%
    Temperature 37*c 38*c
    Pulse rate 72bpm 90bpm
    Respiratory rate 18rpm 27rpm

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