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How to take Patients History


Patients History.
Name: ABC        
Address: ABC
Age: x
Sex: x
Marital Status: x
Occupation: x
Religion: x
 Chief Complaint
The patient came in the emergency with complaint of high grade fever 102*F to 104*F and general body ache from last 4 days. He also vomited 4 to 6 times in last two days but he didn’t see any blood. Due to the body ache he is not stand in any position; swear body painand neck pain.
History of the patient’s illness
  The symptoms started to appear gradually about 5 days back when he returned from work, at first the patient experienced body fatigue with mild fever, next came general body ache with vomiting.                                                                       The patient told he had never had such high fever before. The patient had no idea what caused this condition. As the patient was experiencing this situation for the first time he was not sure of the aggravating or alleviating factors of the problem.
Past History
 On asking the patient and his mother told that he had no major childhood illness. As the patient’s family is illiterate he had never been vaccinated and never experienced any allergies or reaction to any medicine. He had never been hospitalized before and is not using any type of prescribed drugs.
Family history & illness
The patient has 9 siblings (7 sisters and 2 brothers) and 2 patents alive. No record of past illness is present but patients elder brother had the same signs & symptoms before him and was diagnosed with dengue fever. Other than that the patient’s family has no history of a major disease or illness.
Lifestyle
Patient does not smoke, , illicit drugs or recreational drugs. He informed that he takes three meals balanced diet daily and drinks plenty of water. Patient’s mother told that they are not getting clean water so they bring clean water form a different source.                                                                                                               Patients sleep and rest pattern is not altered, he sleeps around 8pm and wakes up at 6 am in the morning. Daily activities include going to work and coming back home.

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