Patient Profile  
Patient Information
Patient Initials: Age:
Gender: Health Insurance (coverage, affordability of meds) : Living
Male Female Arrangement
s:
Allergies
Drugs: Reaction:
Environment Reaction:
:
ADR: Reaction:

Medical Information                                                                                                         
                                      
Chief Complaint/Reason for encounter today:
History of present illness:
Past medical history Family history

Social History
Tobacco use: N 0-1 packs per day
Yes
o >1 packs per day
Alcohol use: N Previous
<2 drinks history
per weekof smoking
2-6 drinks per week
Yes
o > 6 drinks per week, history of alcohol
Caffeine use: N dependence
<2 cups per day 2-6 cups per day
Yes
o > 6 drinks per week, history of caffeine
Other recreational drug use: List: Yes No dependence
Walle University Hospital
W. Street, Hill City

PATIENT MEDICAL PROFILE

Patinet Information
Patient Initials: E. J. Age: 4 years old
Date of Birth: January 1, 2016 Sex: Female Male
Address: Tumaga, Zamboanga City Height: 98cm
Contact Number: 0926 123 8765 Weight: 19kg
Marital Status: Single Married Divorced Widowed
If married, spouse' name:

Living situation:
Lives alone Lives with family Group Home
Supported living Nursing Home Other

Allergies
Drugs: None Reaction:
Environment: None Reaction:

Social History
Tobacco use: 0-1 packs per day
Yes No >1packs per day
Previous history of smoking
Alcohol use: <2 drinks per week
2-6 drinks per week
Yes No
>6 drinks per week, history of
alchol dependence
Caffeine use: <2 cups per day
2-6 cups per day
Yes No
>6 drinks per week,history of
caffeine dependence
Other recreational
Yes No
drug use:

Immunization
Comments:
Acording to the mother the patient wasn't able to get the imuunization for measles because
during those moment they were force to change homes every month due to some conflict.
She stated that she already forgot about the immunization of her child.
Walle University Hospital
W. Street, Hill City
Medical Information
Chief Complaint/Reason for encounter today:
The mother of the child stated that, the child is
experiencing fever for Four (4) consecutive days, there are visible rashes in the child's skin and the child
is crying because of the pain she experience due to those rashes.

History of present illness:

According to the mother just last week, prior to the
appearance of the disease condition the child can still playin the paly ground together with the other kids.
After that event, the child starts to show symptoms of a disease condition wherein upon admission the
patient's temperature is at 38 degreemcelsius, her respiration is 47 beats per minute. The child experince
pain the site of the rashes and it was observed that the pain level is at 6. The child shows feeling of pain
whenever she scratch her rashes that is why the mother will sometimes prevent the child from scratching
the area of the rashes.

Past medical history: Family History:

The patient was admitted
to the hospital when she was 2 years old due to bone Both sides of the family doesn't have history of
fracture caused by an accident. any severe, chronic disease condition.

Current Medication Indication: Start Date: Response

To reduce the fever and to
relief the feeling of pain
Paracetamol
To maintain skin integrity
Vitamin A
The temperature was
lowered to 37.8 degree
11-Feb-20
celsius and the pain level
was decrease to 2
The skin looks hydrated
11-Feb-20 and presence of rashes was
reduce