2. PERSONAL DATA
• Name: lamya
• Gender: Female
• Age: 26 years old
• Occupation: teacher.
• Nationality: Saudi
• Residency: Riyadh city
• Birth: Riyadh city
• Historian: patient who was reliable.
7. HISTORY OF PRESENTING ILLNESS:
• What do you mean by tiredness ?
• Inquires about onset and duration of fatigue ( 1 month )
• Asks patient what she believes is causing her fatigue
• Patients' ideas, concerns, and expectations (ICE)
8. HISTORY OF PRESENTING ILLNESS:
• Inquires about patient’s mood (“I often feel low” for 2 year or so )
• Excessive sleep (yes)
• Feelings of worthlessness/guilt/isolation ( not always )
• Poor concentration ( yes )
• Symptoms of anxiety ( yes )
• Symptoms suggestive of thyroid disease - cold intolerance, skin/hair changes
• Increasing weight, increasing appetite (no)
• Symptoms of DM
• Inquires about association with other systemic symptoms – fever, chills, nausea (none)
• Anaemia symptoms: breathlessness on exertion ( yes )
• Suicidal ideation
• Suicide attempts
9. PAST MEDICAL HISTORY
• decreased blood pressure attacks (multiple times)
• History of HAV 10y ago ( 16 y old ) treated in
Alshmaisy
10. CON.
• Past admission: HAV ( 10 y ago )
• Past surgical: null
• Medication: null
• Blood transfusion: null
• Allergy: no known allergy of food or medication
• Family history: null
• Social history: No recent travel , not smoker , No recent contact with unwell person .
• Vaccination: influnza vaccination ( 2 weeks )
• Pregnancy and periods cycle ?