08 LEM UNIVERSITI SAINS MALAYSIA CLINICAL CASE WRITE-UP COMMUNICABLE DISEASE BLOCK NAME : UMI NADHIRAH AISYAH MOHD ROKHIBI MATRIC NO. : 107550 VC NO. : 900626-02-5634 YEAR 23 TUTOR : DR. MOHAMMAD ZIKRI AHMADPATIENT’S IDENTIFICATION RIN Name : NurFatenSyuhadabini: Muhammad Age 19 years old Address KubangKerian, Kelantan. Gender : Female : Malay ingle Occupation Student Date of Admission: 7/11/2012 Date of Clerking 7/11/2012 Informant : Patient herself CHIEF COMPLAINT The patient NurFatenSyuhada Muhammad, a 19 year-old female Malay was presented to HUSM with the complaint of fever associated with sore throat, joints pain and vomiting S days prior to admission(PTA), HISTORY OF PRESENTING ILLNESS She was apparently well until 5 days ago when the fever developed. Regarding the fever, it was of sudden onset and continuous in nature. It also associated with sore throat, sweating and joint pain. She went to the general practitioner for treatment and was given antibiotics for both fever and sore throat, The fever was apparent at night and early morning, no but relieved by taking Panadol \geravated For the sore throat, it developed simultaneously with the fever. The general practitioner said her left tonsil was swollen so that she was given antibiotic to overcome the swelling. She claimed to experience pain during oral intake. Regarding the vomiting, its onset was abruptly around 2 days prior to admission. ‘There was no nausea but the vomiting was associated with loss of appetite(LOA) and poor oral intake, In the first episode, the vomitus contained food material and was yellowish in colour. She denied any presence of blood in the vomitus. For the subsequent bouts of vomiting, it was whitish and scanty in volume. The frequency of vomiting reported was twice per day. She also stated she had a mild epigastric pain which radiates to the left hypochondriac region. She gave the pain score of 2 out of 10 and claimed it was due to poor ofal intake, loss of appetite and the vorniting bouts.SYSTEMIC REVIEW System Sign & Symptom Findings Genitourinary Dysuria, No Hematuria No Dermatology Discolouration Slightly yellowish Rashes No | Respiratory Shortness of Breath No ‘Cough No "Sore throat Yes Nasal bleeding we Cardiovascular Chest pain No Gastrointestinal Nausea s No Vomiting Yes Musculoskeletal Yolm pila Yes, especially in lower mae limbs Muscle pain No Central Nervous Blurring of vision No Photophobia No Drowsiness No