HISTORY TAKING
BIODATA OF PATIENT:
Name
: Mr.Dikshan kumar
Age
:34 years
Hospital Reg.no.
:115131/N4
Ward
:A-1 ward
Bed no.
:9
Admission date
:25/01/12
Diagnosis
:Diabetic ketoacidosis
Name of doctor
:Dr.Khan
Address
:Kursipara,Bhilai
Name of doctor
:Dr.Khan
Chief complaints:
Patient came with the complaint of abdominal pain,vomiting ,fever,increase in frequency of
micturition and bodyache since 2-3 days.
MEDICAL HISTORY
Present medical history :- Patient had a history of abdominal pain,fever,vomiting,
increase in frequency of micturition and body ache since 2-3 days
Past medical history :-He has a past history of diabetes mellitus but was not on
regular insulin treatment
Present surgical history No past surgical history
Past surgical history :- No past surgical history
FAMILY HISTORY
S.
NAME OF THE
PERSONS
NO
AGE /
SEX
RELATIONSHIP
WITH CLIENT
EDUCATI OCCUPAT
ON
ION
1
Dikshan kumar,
34yrs/M
Self
2
Kirti,
30 yrs/F
Wife
3
Suraj,
6Yrs/M
Son
----
4
Sanjay
3Yrs/M
Son
----
.
Index:
-
Male
-
Female
-
Patient
10 TH
5 TH
Tempo
driver
House wife
SCIO-ECONOMIC STATUS:
His salary is 8,000rs. per month. He is very much cooperative
with family members and neighbours. He maintained good relationship with others. He
is getting full support from his family.
SANITARY CONDITIONS:
Mr. Dikshan kumar, is living in a pucca house. Proper ventilation is maintained,
drainage system and water facility is also in good condition. They are using tap water
for drinking purpose. Disposing the waste in waste garbage near in his house.
Health facility near home:
Type:In their area private nursing home are available.
Distance:2 kilometer.
Transportation:Transport facility available
ENVIRONMENTAL HISTORY
Type of house: Pacca
Ventilation: Adequate
Electricity: Available
Water facility: Tap water
Drainage system: separate, closed
PERSONAL HEALTH HISTORY:
Sleep pattern: Regular
Bladder & Bowel habit: Regular
No allergic reaction to drugs
RELIGIOUS HISTORY:
Religion: Hindu
Religious habits: participating religious activities
Exercise: yoga
NUTRITIONAL HISTORY:
Patient & all family members are non vegetarion they use to take all vegetables & all
varity of non vege.
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