HISTORY TAKING AND PHYSICAL EXAMINATION ASSIGNMENT

CASE STUDY
MEDICAL (ANGINA PECTORIS)

1. Patient Profile:
Patient Name :- Jai Lal Bhadu

Age : 57 yrs

Sex. : Male

Date of Birth : 01/01/ 1978

Religion : Hindu

Marital Status : Married

Education : 5th class passed

Occupation : Farmer

Income : 8000/month

Address : Vill + Post – Bamanwas, , Sawai Madhopur (Raj)

Date of Admission :- 05-08-22

Ward :- Cardiac ward

Date of Data collection :- 07-08-22

Medical Diagnosis :- Angina Pectoris (Coronary Artery Disease)

Name of the surgery :- Not significant

Type of anaesthesia:- Not significant

Date of care started :- 09-08-22

A. CHIEF COMPLAINTS The patient was asymptomatic on the

:
evening of 20/5/2022 when he suddenly developed chest pain radiating to shoulder and left
arm. He was restless and sweating profusely when admitted to cardiology ward during
night.
B. HISTORY OF PRESENT ILLNESS:
Reason of admission : - The patient was asymptomatic 3 months back when he
suddenly developed chest pain which was dull in intensity and was relieved on rest. About
15 days back he again suffered with chest pain which was slightly severe than the last one
but he ignored as it was again relieved on rest. But on the evening of 09/08/22 he suffered
with severe chest pain with sweating and was admitted in cardiology ward.

Intensity of pain scale 0-10 :- 10 number in pain rating scale ( at the of incidence)

Associate symptoms:-

- Fever

- Restlessness

- Anxiety/ Stress

C. PAST MEDICAL AND SURGICAL HISTORY:(Including childhood illness)

Past medical history :- No H/o medical illnesses like DM, asthma,hypertension.

Immunization :- Tetanus Toxoid given 7 year ago.

Past surgical history :- Any surgical incision not performed in client.
Injuries and accidents :- No significant H/O any Injury
Allergies :- No significant H/O any drug allergies.

D. FAMILY HISTORY:
Family status :- Nuclear
 Type of Marriage :- Arrange Marriage

Number of Family Members :- 6

Family history of illness :- Father of client Suffering from Asthma.

Family income per month/year :- 35000/month

Cause of death in parents/siblings :- Parent of client is live at present time.

Age of onset/death :- XX

Genogram (family Tree):

Male

Female

Client

E. PERSONAL HISTORY:
Oral care/Dental : Yes
Smoking Habits : Yes (2 packet/day)
Alcohol habits : No
Sleep pattern : Adequate
Activity-exercise pattern : Moderate

Elimination pattern : Good

Bowel ( Frequency/day) : 2 time in day
Any problem,if Specify : Not significant
Bladder (Frequency/day) : 7-10 time in day
Amount of urine (Characterics) : 1800-2000 ml per day and urine color is amber
pale

F. SOCIO-ECONOMIC CULTURAL HISTORY:

Social History : Client himself is the only bread winner for the family. No
other source of support .
 Present occupation : Farmer
Monthly Income : 8000 Per Month
Marital Status : Married
Housing : Own
Name of the place( Village/city) : Village

G. NUTRITIONAL HISTORY:
Diet pattern (vegetarian/non vegetarian) : Vegetarian
Likes and dislike of patient : Like
Appetite ( Good/moderate/poor) : Good

II. PHYSICAL EXAMIATION:

A.General Appearance:
Level of consciousness : Oriented
Body posture : Standing
Gait : co-ordination
Body movement : Purpose full
Hygiene and grooming : Dress appropriate
Affect and mood : Appropriate

B.VITAL SIGNS:
Temperature : 100* F site : Oral
Pulse : 110
Rate : Tachycardia
Rhythm : Regular interval
Quality : weak
Pulse scale : 2+ (Steady)
Respiration
Rate : 38 /minute (Tachypnea)
Rhythm : Regular
Depth : Shallow
Effort : Effortless
Oxygen saturation : 85%
Blood pressure: LA 150/95 mmHg (lying)

C. INTEGUMENTARY SYSTEM :
INSPECTION
 Skin Color : Ruddy
Skin Intergrity : Good (Elasticity is present )
Nail : Clean
Nail color and shape : Pale and Thickned
Cyanosis : Not significant
PALPATION:
Temperature : Normal
Turgor : Notenting
Edema : Cutaneous
Texture : Rough
Edema Scale: Dent Depth and duration

D.HEAD AND NECK :

INSPECTION:
Shape and size : Rounded
Hair : Currly hair
Quantity : Normal
Hair loss : Not significant
Scalp : Dandruff
Infestation : Any infectious manifestation not found.
Face : Tenderness

PALPATION:
Temporal arteries : No tenderness

E. EYES
INSPECTION:
Eyebrows : Equal hair distribution
Eyeball : Normal
Visual Acuity : Myopia
Eyelids : Swelling (Right)
Eye lashes : Redness

F. EAR
INSPECTION/PALPATION:
Ear : Equal
 Pinna : Normal
Canal : Pink
Erythema/foreign bodies:- Not found
Hearing voice Test : Normal
G.NOSE AND SINUS :
Patency of nares : Normal air entry
Sense and smell : Not significant due to client in Coma.
Turbinates : Moist

H.MOUTH AND THROAT :

Lip : Pink /dryness:-
Buccal mucosa : Discolour , lesions of lips,
Tongue : Smooth, pink, moist.
Teeth : Clean and missing teeth(lower incisor)
Palates and uvula : Pink , soft and smooth palate.
Tonsils : Pink

I. NECK
INSPECTION AND PALPATION
Face : Normal facial expression
Neck : Movable
Lymph Node : Not palpable
Thyroid gland : Non palpable
ROM and muscle strength : Full Range Of Motion (good)

J. CHEST
BREAST AND AXILLAE

INSPECTION:
 Skin : Redness

Contour : Flattening
Nipple size and shape : Rounded and equal.

PALPATION:
Breast
Mass shape : Round
Consistency : Soft
Lymph Nodes : Movable nodes
K. RESPIRATORY SYSTEM
INSPECTION:
Chest wall : Prominent ribs
Size and Shape : Normal diameter diameter
Cough : Not present
Sputum : Productive( Yellow and redish color, 50 ml )
Colour : Yellow bloody
Consistency : Thick, mucoid frothy, rusty, smell and history of smoking
Specify preferred position:- Semi fowler position
PALPATION:
Skin temperature : Hot
Trachea : Normal aligment
Chest : Tenderness
AUSCULATION : (Specify in detail: left and right lungs and upper and lower lobes)
Air entry : Bilaterally equal
Diaphragmatic excursion : Symmetry
Breath sounds : Rustling noise
Abnormal Sounds : Stridor

L. CARDIVASCULAR SYSTEM
PALPATION
Carotid arteries (left and right): Right
Pulse rate : 110 and regular
Perpheral pulse : 110 in uppar extremity (radial)
Oedema : Not significant
AUSCULATION :
Bruit sound :- Absent
Blood pressure :- RA (180/110 mm of hg)
Lying :- 170/95 mm/hg
Heart rate : 110 (Tachycardia)

M. GASTROINTESTIONAL SYSTEM
INSPECTION:
Abdomen : Symmetry
Abdomen pain : Not significant
Rectal Exam : Not significant any abnormality
N. MUSCULOSKELETAL SYSTEM
INSPECTION :
Upper and lower extremities : Redness and stiffness.
PALPATION:
Joints : Crepitus and thickening

RANGE OF MOTION;
Neck : Rotation
Spine : Rotation
Shoulders : Movement is present
Elbows : Movement is present
Wrists : Movement is present

III. NEUROLOGOCAL ASSESSMENT:

i. Mini mental status examination :
Behaviour : Restless, clam and grimcing
Orientation : Client fully aware about Time, Place, and
person.
Memory/concentration : Immidiate
Level of consciousness : Fully conscious
 Glascow coma scale:

Features Response Score Patient’s score Inference

Eye opening Spontaneous 4 4
To speech 3
To pain 2 Same time client
open eye by
pain(chest rubbing)
None 1
Verbal Oriented 5
Confused conversation 4
Inappropriate (word) 3
Incomprehensive(sound) 2
None 1 4 No response of
client
Motor Obeys commands 6
Localises to pain 5
Withdraws from pain 4
Flexion to pain 3
Extension to pain 2
None 1 6 No motor response
of client by
commands and
pain.
Total score 15 14

IV. Pupillary assessment : (Left and Right eyes)

Pupil size : 3mm (NORMAL)

Shape : Round
Reaction to light : Reaction to light is absent

V. INVESTIGATIONS :
S. No. Name of the Patient Value Normal Value
investigation
1 Blood Sugar 120mg/dl
(random)
2 Serum urea 28mg/dl 15-45mg/dl
3 Serum Creatinine 1.20mg/dl 0.6-1.6mg/dl
 4 Serum total bilirubin 0.7mg/dl 0-1.0mg/dl
Direct
Indirect 0.3mg/dl
0.4mg/dl
5 SGOT 34U/L 0-4 U/L
6 SGPT 235U/L 5-36 U/L
7 Serum CPK-MB 25 U/L 0-24 U/L
8 Triglyceride 76 mg/dl 10-180mg/dl
9 Total cholesterol 130mg/dl 130-250mg/dl
10 HDL 49 mg/dl 30-66mg/dl
11 LDL 68 mg/dl <155mg/dl
12 VLDL 18 mg/dl <35 mg/dl
13 DLC
Neutrophils 82.6% 40-80%
Lymphocytes 11% 20-40%
Monocytes 6.7% 2-10%
Eiosinophils 2.1% 1-6%
Basophils 0.8% 1-2%
14 CBC
Hb 15.4 14-18gm/dl
TLC 8.33 4.3-10 thous./cumm
4.5-6.3million/cumm
Total RBC 4.57 77-93femolitre
26-32 picogram
MCV 91.7 32-36 gm/dl
MCH 28 1.4-4.4 lakhs/ml
MCHC 29.7 40-54%
Platlet count 2.68
PCV 51.5
15. ECG
 ST segment Depression, T wave inversion

16. Echocardiography
 Calcification of Aortic valve
 mild tricuspid regurgitation
 Cardiac LVH

VI. DRUG PROFILE:

Name of the drug Dose Route Action Side effects
Inj.Enoxapam 60mg BD Sc
Inj. Amoxiclave 125mg TDS IV
Tab. Aspirin 150mg OD Oral
Tab. clopidegral 75 mg OD ‘’
Tab. Atorvastatin 40 mg OD ‘’
Tab. remipril 2.5 mg OD ‘’
Tab. ISMH 20 mg BD ‘’
Tab. ISDH 5 mg SOS Oral
Inj. Lasix 1 amp. BD IV
Tab. levoflox 50 mgTDS Oral

VII. Related Anatomy and physiology (with diagram):

A. Heart and heart wall layers
1. The heart is located in the left side of the mediastinum.
2. The heart consists of three layers.
 The epicardium is the outermost layer of the heart.
 b. The myocardium is the middle layer and actual contracting muscle of the heart.
 c. The endocardium is the innermost layer and lines the inner chambers and heart
valves.

B. Pericardial sac
1. Encases and protects the heart from trauma and infection
2. Has two layers
a. The parietal pericardium is the tough, fibrous outer membrane that
attaches anteriorly to the lower half of the sternum, posteriorly to the
thoracic vertebrae, and inferiorly to the diaphragm.
b. The visceral pericardium is the thin, inner layer that closely adheres to
the heart.
3. The pericardial space is between the parietal and visceral layers. It holds 5 to
20mL of pericardial fluid, lubricates the pericardial surfaces, and cushions the
heart.

C. There are four heart chambers

1. The right atrium receives deoxygenated blood from the body via the superior
and inferior vena cava.
 4. The right ventricle receives blood from the right atrium and pumps it to the
lungs via the pulmonary artery.
5. The left atrium receives oxygenated blood from the lungs via four pulmonary
veins.

D. Coronary arteries:
Supply the capillaries of the myocardium with blood
1. The right main coronary artery supplies the right atrium and ventricle, the
inferior portion of the left ventricle, the posterior septal wall, and the
sinoatrial and atrioventricular nodes.
2. The left main coronary artery consists of two major branches, the left anterior
descending and the circumflex arteries.
3. The left anterior descending artery supplies blood to the anterior wall of the left
ventricle, the anterior ventricular septum, and the apex of the left ventricle.
4. The circumflex artery supplies blood to the left atrium and the lateral and
posterior surfaces of the left ventricle.
VIII. DISEASE CONDITION :

A. Introduction
obstruction of coronary blood flow because of atherosclerosis, coronary artery spasm, and

conditions increasing myocardial oxygen consumption.

B. Definition :-
Angina is chest pain resulting from myocardial ischemia caused by inadequate myocardial

blood and oxygen supply. Angina is caused by an imbalance between oxygen supply and

demand.

C. Patterns of angina
1. Stable angina
a. Also called exertional angina
b. Occurs with activities that involve exertion or emotional stress and is relieved with
rest or nitroglycerin
c. Usually has a stable pattern of onset, duration, severity, and relieving factors
2. Unstable angina
a. Also called preinfarction angina
b. Occurs with an unpredictable degree of exertion or emotion and increases in
occurrence, duration, and severity over time
c. Pain may not be relieved with nitroglycerin.
 3. Variant angina
a. Also called Prinzmetal’s or vasospastic angina
b. Results from coronary artery spasm
c. May occur at rest
d. Attacks may be associated with ST segment elevation noted on the
electrocardiogram.
4. Intractable angina is a chronic, incapacitating angina that is unresponsive to interventions.

5. Pre-infarction angina
a. Associated with acute coronary insufficiency
b. Lasts longer than 15 minutes
c. Symptom of worsening cardiac ischemia
d. Characterized by chest pain that occurs days to weeks before an MI
Causes Of Angina Pectoris

Book picture Patient picture

 Previous cardiac disease o No
 Old age o No
 Tobacco smoking o Yes
 High blood level of LDL and
triglyceride o No
 Low level of HDL o No
 Diabetes o No
 High blood pressure o Yes
 Lack of physical activity o Yes
 Obesity o Yes
 Chronic kidney disease o No
 Excessive alcohol consumption o Yes
 Use of cocaine and amphetamines
o No
 Chronic high stress level
o Yes

Clinical manifestation :
Book picture Patient picture
 Chest pain radiating to  Yes
neck, jaw, shoulder, back
or left arm
 Epigastric pain  No
stimulating Indigestion
 No
 Nausea
 Shortness of breath and  Yes
difficulty breathing
 Yes
 Unexplained anxiety,
weakness or fatigue  No
 Palpations, cold, sweat.
Pathophysilogy :

Change in the condition of plaque in the coronary artery


Activation of platelet

thrombus

Ischemia of tissue in the region supplied by the artery
enzymes
Coronary blood supply less than demand

Myocardial cell death

Diagnostic Evaluation :

Book picture Patient picture

 Electrocardiograpy o Yes
 CK-MB o No
o No
 Myoglobin
 Troponin (cardiac troponin T o No
and I)
 LDH o No
o No
 AST
o Yes
 Leukocyte count
 PET o No
 Echocardiography
o Yes

Management:
 Medical Management:

Book picture :- Patient picture:-

 Administer oxygen  Yes

 Start IV line  Yes

 Morphine sulphate  Yes

 Thrombolytic therapy  Yes

 Beta blockers  Yes

 Bed rest for first 24 hours  Yes

 Range of motion exercise  yes

Nursing management:
Book picture Patient picture

 1. Obtain a description of the chest discomfort.  1. Yes

 2. Administer oxygen by nasal cannula as prescribed  2. Yes
 3. Monitor vital signs and cardiovascular status and  3. Yes
maintain cardiac monitoring.
 4. Ensure bed rest and place the client in a semi-Fowler’s  4. Yes

position to enhance comfort and tissue oxygenation; stay

with the client.  5. Yes
 5. Assist to establish an IV access route.  6. Yes
 6. Obtain a 12-lead ECG.  7. Yes
 7. Assist to administer antidysrhythmic as prescribed.
 8. Assist to administer thrombolytic therapy, which may be  8. Yes
prescribed within the first 6 hours of the coronary event.
 9. Monitor for signs of bleeding if the client is receiving  9. Yes

thrombolytic therapy.  10. Yes

 10. Monitor laboratory values as prescribed.  11. Yes

 11. Administer β-blockers as prescribed to slow the heart  12. Yes

 12. Monitor for complications related to the MI.

 13. Yes
 13. Monitor for cardiac dysrhythmias because tachycardia
and PVCs frequently occur in the first few hours after MI.
 14. Yes
 14. Monitor distal peripheral pulses and skin temperature
because poor cardiac output may be identified by cool
 15. Yes
diaphoretic skin and diminished or absent pulses.
 15. Monitor intake and output.

Complications:
 Book picture Patient picture

 Dysrhythmias o No

o No
 Cardiogenic shock
o No
 Heart failure and pulmonary
edema o No
 Pulmonary embolism
o No
 Recurrent MI
o No
 Pericarditis
o No

NURSING PROCESS :

Problem identified:
 Hyperthermia
 Restlessness
 Client look dull and lethargy.
 Unable to speech because client in coma.
List of nursing diagnoses as per priority (short/long term)

 Altered breathing pattern related to accumulation of mucus into the alveolar sac as manifested by shortness of

breathing and oximetry value of oxygen%.

 Altered blood circulation related to abnormal blood supply to heart as manifested by delayed capillary refilling.
 Inadequate nutritional status less than body requirement related tolerance and fatigueness
 Deficient knowledge therapeutic regimen related to inaccurate follow up`as evidenced by non compliance of
medications
 Ineffective role performance related to changes in physical health as evidenced by change
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION EV

Subjective date: Altered breathing -Provide comfortable -Provided high fowler’s position. 

Patient say that- I feel very pattern related to position, high fowler’s -Provided oxygen therapy.

anxious and feel difficulty accumulation of position -Provided medications as

to breathing. mucus into the -Provide oxygen therapy. prescribed by doctor.

alveolar sac as -Provide medications as -Provided good posture to the
Objective data: manifested by prescribed by doctor. patient
Forcefully breathing, altered shortness of -Provide good posture to
oximetry value breathing and the patient
oximetry value of
oxygen%.

Subjective date: Patient provided comfortable
Patient say that I feel Altered blood -Patient provide position.
comfortable position.
numbness in the lower circulation related to -Maintained input and output chart
-Maintain input and output
extrimities abnormal blood chart -Administered fluid as prescribed
supply to heart as -Administer fluid as -Provided good nutritional diet as
prescribed
manifested by prescribed
Objective data: -Provide good nutritional
delayed capillary diet as prescribed -provided medications as
Delay Capillary refilling
refilling. -provide medications as prescribed 
prescribed.

Subjective data; -Povide comfortable -Povided comfortable position

Patient say that I feel very position
fatigue and weakness Inadequate -Administered medications as
-Administer medications prescribed by doctor
nutritional status less as prescribed by doctor
than body -Maintained intake output chart
Objective data: -Maintain intake output
Observed the poor turgor of requirement related chart -Provided good nutritional and high
skin and dry skin and output protein diet
chart tolerance and
-Provide good nutritional
fatigueness
 and high protein diet.


Subjective data :-
Client say, “ May I know
about the disease condition -Assess the level of -Assessed the knowledge the
and its treatment. and knowledge including patient is not knowing the disease,
home care . Deficient knowledge educational status.
therapeutic regimen and he studied up to 10th std
related to inaccurate -Explain about the disease
follow up`as -Explained about the disease
condition and home
evidenced by non care ,in a simple way. condition and treatment, and
Objective Data :
Client looks worried, and compliance of home care activities in a simple
medications -Allow the patient to way by using A.V.Aids
asking many question express their doubt
-Allowed the patient to express
-Answer all the question,
their doubt, he is asking many
that the patient asked
questions.

-Answered all the questions in 

simple way with explanation
Subjective Data :
Patient Complaints, “ I am -Identify type of role -Patient shows role dysfunction
unable to continue my job” Ineffective role dysfunction observe stress
providing situation -Observed stress providing
Objective Data : patient is performance related
situation and avoid the situation.
-Discuss perceptions &
having confusion, worried. to changes in significance of the -Discussed about the disease
situation as seen by client condition & its management
physical health as
-Advise the family -Advised the family members to
evidenced by change members to assisst the
patient assist the patient in daily activities.

-Reassess about role

dysfunction

IX. DIET PLAN:

NAME:- Jai Lal Bhadu
AGE:- 57
SEX:- Male
HEIGHT:- 167 cm
WEIGHT:- 56
GENERAL APPERANCE:-
WORKING STYLE:- heavy worker
RECOMMENDED DAILY ALLOWNCE:-

X. HEALTH TALK:
1.Live a healthy life style.
2.Avoid stress.
3.Teach the patient to continue the medication.
 4.Avoid fatty diet.
5.Stress on exercise.
6.Be aware of the signs of complication- chest pain, dyspnea, diaphoresis.
7.Importance of regular checkup and follow up.
8.Avoid alcohol, smoking, tobacco chewing etc.
9.Stay healthy and eat healthy.
10. Educate client for Morning walking.

XI. Summary :
On the date of 08/04/2021 I had to take the history of the the client of Mr. Jai
Lal Bhadu, I had collect her personal data about her health status family history, after these all collection
of history I found the client is suffering from restlessness and chest pain that all are problem effects
person health continuously . after collection and knowing the client problem I had to discuss with
CARDIAC WARD STAFF and give the Care according to his symptoms occurrence. Here in this case study I
mention all care gived information about the patient for eg. history taken , physical examination,
position changes and also giving the nursing care according to nursing process.

XII. Conclusion :
After collection of all kind of information about the client I had give the care to

the client according her symptoms and patient feel quite comfortable after nursing care.

XIII. Reference:
 brunner & suddarth's, Medical-Surgical Nursing. South Asian Edition 13 th . Welters Kluwer India

Pvt. Ltd. 2018

 Nugent, Green, Hellmer Saul, Pelikan. Mosby's NCLEX-RN. 20TH Edition.2019

 https://images.app.goo.gl/TPb6sJNMByJAg8YQ6

Msc NURSING
 EVALUATION FORMAT FOR NURSING CARE STUDY-1

ADVANCED NURSING PRACTICE

Name of the patient: Ward: Cardio - Intensive Care Unit

Year: 2021 Date:

Subject: Advanced Nursing Practice Evaluator:

Topic: Coronary Artery Disease (Myocardial infraction)

Remarks:

Signature of the Student Signature of the Evaluator

SL CRITERIA MAX MARKS OBTAINED

No. MARKS

1 INTRODUCTION 2

2 Patient profile 2
3 Health history 10

4 Personal history 5

5 Socio economic history 5

6 Physical assessment 5

7 Investigations 5

8 Treatment 5

9 Correlation of book and patient’s features 10

10 List of nursing diagnoses 5

11 Nursing process application 20

12 Health education 4

13 Therapeutic diet plan 5

14 Continuity of care/rehabilitation 5

15 Summary 2

16 Personal evaluation 2

17 Submission of plan on time 2

18 Write up style 2

19 Reference 2

20 Innovation 2

TOTAL:- 100