HISTORY TAKING REPORT

CLINIC VISIT

KUALA LUMPUR CITY HALL (DBKL) CLINIC

9th & 18th January 2012

NAME: ID NO: PBL GROUP:

MOHAMAD SAHIR BIN ZULKIFLI ME0211030365 E1

CASE 1 Personal Details Patients Name: Muhammad Hasan Age Sex Ethnic Religion Occupation : 31 : Male : Malay : Islam : Clerk

Marital Status : Married but no kids Address : 040015, Km 4, Flat Seri Melaka, Jalan Cheras

Chief complaints Patient comes with pain in the toe for one day

History of Presenting Illness Patient experienced pain in the toe of left foot. He said this pain may be due to his gout condition which he got nearly 3 years ago. The pain comes with fever and no temperature is recorded about that fever. Due to his gout condition, in previous consultation with other doctor, he is advice not to eat seafood and nuts. He also thinks that this pain is caused by him not following the doctors advice. He takes painkillers in order to relieve the pain. Before this, he was an active person, but this condition has affected his works. Family history His grandfather also has gout. His other family member does not have any non communicable disease i.e. hypertension, diabetes or cardiovascular disease.

CASE 2 Personal Details Name Age Sex Ethnic Religion Occupation : Farid : 30 : Male : Malay : Islam : DBKL Clerk

Marital Status : Married with two kids Address : Jalan Ipoh

Chief complaint Patient comes with fever for two days

History of Presenting Illness Patient complained of fever. His body was hot during the night. The fever makes his body weak and accompanied with cough and flu. He did not take his own temperature. He taught the hot weather may cause the fever. To relieve the fever, he took Panadol twice a day since the fever started. The drugs helped to bring down the fever but not for long as the fever came back. Resulting from that fever, he slightly loss his appetite. When asked about his neighborhood, he answered that the cleanliness is controlled and the drain is not clogged. Family History His kids did not have fever. He and his family did not have any history of diabetes, hypertension of cardiovascular problem

CASE 3 Personal Details Name Age Sex Ethnic Religion Occupation : Rusli @ Husin bin Ismail : 40 : Male : Malay : Islam : DBKL Driver

Marital Status : Married Address : * patient did not reveal his address

Chief complaint Patient known for diabetes for 10 years coming for wound cleansing

History of Presenting Illness Patient has history of diabetes for ten years. He only took his diabetic medications on several occasions. He has just undergone leg amputation a week before and being released from hospital for the last 3 days. 3 digits of his left foot were amputated. They are 2nd, 3rd and 4th digit. The wound was large and deep. When walking, he felt sharp and throbbing pain. To reduce the pain, he needed to sleep with his amputated foot higher than his body. As the wound cannot come in contact with water, he took his bath with the foot covered by plastic. Before coming to this visit, he applied cream suggested by a private practitioner, Mebo Burn Ointment to apply on his wound. Due to that amputation, he has been given a long leave from work and it slightly affected his income. Family history His late mother has diabetes. His kids did not have diabetes or any other non communicable disease.

CASE 4 Personal Details Name Age Sex Ethnic Religion Occupation : Raojani bin Ahmad : 57 : Male : Malay : Islam : DBKL Civil Worker

Marital Status : Married with two kids 1 girl 1 boy Address : Flat Perumahan Awam Sri Pinang

Chief complaint Patient complained of pain in the ear for two weeks

History of Presenting Illness Patients said that the pain started suddenly especially when he is using cotton bud to clean his left ear. The pain is located in the middle ear. He experienced tickling pain and there is puss coming out of that ear. The pain did not radiate to any part of the face or body. The pain came alone, without any fever or any other symptoms. He has come to this clinic before and the doctor gave him antibiotic and eardrops to control the infection. The doctor also advised him not to clean his ear using cotton bud. However, he complains that he developed allergic reaction to the antibiotic. He experienced itchy skin when he took the antibiotic. He stopped using that antibiotic ever since.

Family History His family member does not have any ear pain. His father has history of cardiovascular disease. He did not know about his kids condition as they already married and live separately.