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UNIVERSITY OF MALAYA

FACULTY OF MEDICINE BACHELOR OF MEDICINE & SURGERY ( MBBS 10/15 ) PHASE IIIA 12/13

CASE WRITE-UPS

NAME : MUHAMMAD AZLAN BIN ASERI REG NO : MEM100093

29/8 - 1 For history taken from the mother, Muhammad Alif, 1 year-old malay boy, was admitted 2 days ago to HTAR with a chief complaint of fever for 7 days prior to admission. Alif was apparently well until a week ago when the chief complaint started. The fever had not subsided for 7 days, occurred intermittently, nocturnal in period. Temperature was not measured. No medication was prescribed to relieve the fever. The fever was associated with post-nasal drip, cough, shortness of breath and rash. The patient started to have post-nasal drips during the onset of fever and had not subsided until current admission. While the cough started 5 days ago and had run for 4 days in duration before subsiding. The cough was intermittent, not severe, productive with moderate amount of greenish sputum, self-limiting and it went away without any medication. The patient also had shortness of breath which began 7 days ago. It was sudden in onset, accompanied by wheezing and dysphonia. The dyspnea had not relieved until admission. Currently, the patient is put under antibiotic medication. On birth, Alif was delivered full term, natural onset through vagina. Period of birth is on march 2011. He had no jaundice at birth. He was breastfed until 7 month old and was put on formulated milk onward. He also whined for semi-solid food on the same age. He had been given complete immunization in 18 months in accordance to schedule. No abnormal growth and development were noted. He had no past medical and surgical history. There are no known drug and food allergy history. The patient was not given any supplement and traditional medicine. There is no other family members had the same problem. However, there is history of diabetes mellitus type II by the mother. Patient is currently taken care by the parents or baby-sitter when the parents are out for work. They stay in home shop which is on 3rd floor. His mother is working as factory worker and his father is a driver. Total household income is about RM2500

and the mother claimed they had no financial problem. None of the patients parent is a smoker. In summary, Muhammad Alif, 1 year-old malay boy, was admitted 2 days ago to HTAR with a chief complaint of fever for 7 days prior to admission.

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