Thursday, September 23, 2010
history taking- medicine
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ward 4B
bed: 1
name: yunus bin musa
age: 21
religion: islam
race: malay
nationality: malaysian
address: section 6 shah alam
occupation: engineering student UI Tee eM
date of admission:30 april 2011
date of clerking: 10 may 2011
chief complaint: mentally disstress for about 3 years
History of presenting illness
site:-NA
character: severe remittent mentally distress
location:-NA
onset:July 2007
radiation:-
associated symptoms: nausea, joint pain (interphalange, shoulder, sacrolumbar, elbow joint), chest pain, loss of weight, amnesia
history of medical illness
premature born, childhood asthma. No chronic illnesses. Being hospitalized under incubator just after born. Never undergoing any surgery except circumsicion. No allergy.
family history
father had a history of femoral hernia, hypotension and gout. mother had severe asthma. 3 siblings all healthy. late grandmother died if myocardial infarction. late grandfather died of stroke.
social history
non smoker, non drinker. not having any girlfriends. not practising ikhtilat. in affliation with an Islamic NGO and engineering student association. practising strict islamic teachings. hate to see best friends, own sisters, classmates and his own race practicing ikhtilat, negligence of prayer, not reading and understanding al-Quran, listening to forbidden music, and other negligences of islamic teachings in front of him. He was always asked to find participants for islamic programs but often too shy, not having enough time, lack of new friends, and too tired after posting session. Often, none of any of his friends will follow and participate the program and not even giving expected responses. Many of his reliable friends start to be involved with jahiliyyah.
general examination
patient is self-oriented and reliable
vital signs:
-pulse pressure: 120 beats per minute (fast and iregularly irregular)
-bloodpressure: 140/100mm hg
-respiratory rate: 20/min
-temperature:37.6 c
eyes: deep sadness, no sign of happiness, sclera is slightly yellowish, conjunctiva anterior and posterior border not significant.
mouth: bad breath, not well hydrated, missing 12, on orthodontic appliances.
neck: jvp-, carotid pulse palpable
hand: peripheral cyanosis
leg: pitting edema
differential diagnoses
bed: 1
name: yunus bin musa
age: 21
religion: islam
race: malay
nationality: malaysian
address: section 6 shah alam
occupation: engineering student UI Tee eM
date of admission:30 april 2011
date of clerking: 10 may 2011
chief complaint: mentally disstress for about 3 years
History of presenting illness
site:-NA
character: severe remittent mentally distress
location:-NA
onset:July 2007
radiation:-
associated symptoms: nausea, joint pain (interphalange, shoulder, sacrolumbar, elbow joint), chest pain, loss of weight, amnesia
history of medical illness
premature born, childhood asthma. No chronic illnesses. Being hospitalized under incubator just after born. Never undergoing any surgery except circumsicion. No allergy.
family history
father had a history of femoral hernia, hypotension and gout. mother had severe asthma. 3 siblings all healthy. late grandmother died if myocardial infarction. late grandfather died of stroke.
social history
non smoker, non drinker. not having any girlfriends. not practising ikhtilat. in affliation with an Islamic NGO and engineering student association. practising strict islamic teachings. hate to see best friends, own sisters, classmates and his own race practicing ikhtilat, negligence of prayer, not reading and understanding al-Quran, listening to forbidden music, and other negligences of islamic teachings in front of him. He was always asked to find participants for islamic programs but often too shy, not having enough time, lack of new friends, and too tired after posting session. Often, none of any of his friends will follow and participate the program and not even giving expected responses. Many of his reliable friends start to be involved with jahiliyyah.
general examination
patient is self-oriented and reliable
vital signs:
-pulse pressure: 120 beats per minute (fast and iregularly irregular)
-bloodpressure: 140/100mm hg
-respiratory rate: 20/min
-temperature:37.6 c
eyes: deep sadness, no sign of happiness, sclera is slightly yellowish, conjunctiva anterior and posterior border not significant.
mouth: bad breath, not well hydrated, missing 12, on orthodontic appliances.
neck: jvp-, carotid pulse palpable
hand: peripheral cyanosis
leg: pitting edema
differential diagnoses
- chronic distress syndrome
- futur (lost in the pathway of da'wah)
- weakness of iman
- lack of amal jamaie
- involve in mild ikhtilat
- lack of knowledge
- lack of ibadah
- burn-out syndrome
- heavy course
- signs of kiyamat
- angina
- oesophageal spasm
- anxiety
- MI
Investigation: NA
management
- mutabaah amal- ma'thurat, quran, subuh maghrib and isya prayer in jemaah, giving charity
- motivation
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