Duncan Mapeto Banda Subjective Assessment report is a product of My second clinical document at University Of malawi, college Of medicine

1. PATIENT SUBJECTIVE ASSESSMENT-MEDICAL REPORT
Hospital name: Queen Elizabeth Central Hospital (QECH)
Examiner: Duncan mapeto Banda, student Physiotherapist, ID: 201250022003
Supervised/Invigilated by: Alex Dzinkambani, Isaac Chapweteka & Stella
Candidate/Client Information:
Bed number & ward: ward 6A & bed number 41
Fist name: Blessings
Last name: Mpinde
Date of Birth: 24th March 1993
Sex: Male
Marital status: Single but with one girl friend
Primary language: Chichewa
Spirituality/Religion: Christian, CCAP
District of origin: Mulanje, T.A Mabuka, Namazoma Village
Current residence: Hospitalised directly from homeland
History taking and secondary assessment
History Of present illness or Present Medical history:
Problem: Osteochondoma based on health passport (patient said Chotupa, Tumour) on
the knee
Onset: startedon its own and gradual in 2009
Date of admission: 26th April 2015
Pain: Not painful before surgery but experiences pain due to surgery
Pain description: localisedon knee, very painful soon after surgery, not pain when
limb is not moved, pain worsens when limb is liftedor bent
Treatment: surgery
Surgical date: 27th April 2015
Additional information: No other symptoms such as numbness, weakness, or pins and
needles sensation
Mode of patient Clinical visit: Referredfrom MulanjeDistrict Hospital (Mulanje
DHo)

2. Past Medical history or Past Medical History:
Medications/ Current Medications or Herbal Supplements: No
Admitted before/Hospitalizations: No
Surgical before/Past Surgeries: No
Chronic Medical Problems: No
Medication Allergies/Reaction: No
Family line disease or problem: migraine (mutuwaching’alang’ala)
Family history:
Family structure: Nucleated family (7 members)
Family members: Father, Mother, two sons & three daughters
Significant medical problems for any blood relatives: No
Social history:
Exercise: plays football
Tobacco use: Yes, though smokes rarely, Embassy type of tobacco
Drink alcoholic beverages: Yes, but rarelymostly during celebrations e.g. Charismas
& New Year
Caffeine: No
Current main occupation: Tea Estate Clerk
Usual duties: General fitting, farming
Leisure: chats with friends at home or around the village.
Effect of illness/current problem on daily activities: No effect i.e.he worked
normally with the problem
NB: because he worked normally, I asked “what made him to go to the hospital; he
said the problem (swelling) kept growing though he could work normally.
Assessmenttook place at Queen ElizabethCentral Hospital, Malawi, 29th
April2015, 9-10Am, by Duncan
Mapeto Banda, Malawi Collegeof medicine Physiotherapy student.