8/3/2019 History Taking Report ( fried -mamak style)

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HISTORY TAKING REPORT

CLINIC VISIT

KUALA LUMPUR CITY HALL (DBKL) CLINIC

9th

& 18th

January 2012

NAME: MOHAMAD SAHIR BIN ZULKIFLI

ID NO: ME0211030365

PBL GROUP: E1

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CASE 1

Personal Details

Patients Name: Muhammad Hasan

Age : 31

Sex : Male

Ethnic : Malay

Religion : Islam

Occupation : 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.

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CASE 2

Personal Details

Name : Farid

Age : 30

Sex : Male

Ethnic : Malay

Religion : Islam

Occupation : 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

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CASE 3

Personal Details

Name : Rusli @ Husin bin Ismail

Age : 40

Sex : Male

Ethnic : Malay

Religion : Islam

Occupation : 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 hospitalfor 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.

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CASE 4

Personal Details

Name : Raojani bin Ahmad

Age : 57

Sex : Male

Ethnic : Malay

Religion : Islam

Occupation : 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.