Report: Patient Case Study

Jun 18th, 2015
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Pn. Siti Khadijah a 58 years old women was diagnosed with hypertension since 5 years ago. However, she does not develop any complication of hypertension. 3. Clinical history Chief complaint: Pn Siti Khadijah has hypertension. History of presenting illnesses: She was apparently well until 5 years ago where she had a headache and a syncopal attack. The headache was sudden onset and was felt at the occipital area. It was triggered by stressful activity throughout her daughter’s wedding ceremony. By the end of the tiring day, she had a severe headache and fainted. She was brought to clinic Banting by her family members and noted her blood pressure was very high which is 200/110 mmHg. She was referred to Banting hospital after that and was admitted for 3 days. After her condition was stabilized,

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Report: Patient Case StudyName: Muhammad Aiman Bin ZainalMatric. No.: 0808-0866Year: Year 3, MBBS 2008Posting: Public Health & Community MedicineDates of visit: 16.3.2011, 24.3.2011, 31.3.2011Table of contentsNoContentsPage No1.Patient details12.Introduction: Case Summary23.Clinical History2 4 4.Evaluation of physical & psychosocial environment55.Belief and understanding of illness66.Impact of illness and family6 7 7.Evaluation on patients need78.Evaluation on communication89.Evaluation on patient need for community care and support810.Wellness diagnosis8 911.Wellness intervention1012.Discussion11 12 13.References121. Patient DetailsPatients name: Pn. Siti Khadijah Abdul MalikAge: 58Date of Birth: 19th December 1953Occupation: Factory canteen food providerAddress: Jln. Pinang Muda, Kg.Bukit Bangkong.Race: MalayReligion: IslamMarital status: MarriedFamily members: 3 sons and 3 daughters (from age: 41 years old to 15 years old)Height: 154 cmWeight: 80kgDiagram 1: Me and my patient. 2. Introduction / Case SummaryPn. Siti Khadijah a 58 years old women was diagnosed with hypertension since 5 years ago. However, she does not develop any complication of hypertension. 3. Clinical historyChief complaint:Pn Siti Khadijah has hypertension.History of presenting illnesses:She was apparently well until 5 years ago where she had a headache and a syncopal attack.

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