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.
