Professional Documents
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KOLEJ PEMBANTU
PEMBANTU PERUBATAN
PERUBATAN
ALOR SETAR
CASE CLERKING
CASE CLERKING
No.Matrik :DBMA11-6071
Tahun :2 S emester :2
-TIDAK PERLU-
Nama:
Hospital/Klinik: Tarikh:
HOSPITAL SULTANAH BAHIYAH MASUK WAD:
17-01-2013 @
8.23 AM
KELUAR WAD:
19-01-2013 @
9.10 AM
BAHAGIAN 2: RIWAYAT PESAKIT
Aduan Utama:
a) Patients have complained of bumps in his scrotum
b) Bumps more prominent (kelihatan) and growing.
c) Noticed around 8 pm last night (16/01/2013)
d) Referred case from Hospital Jitra for irreducible right inguinal hernia
Sejarah Penyakit
(Termasuk alahanLalu:
ubatan)
Sejarah Keluarga:
1. Mother
i) NIL
2. Father
i) NIL
Sejarah Sosial:
Sejarah O&G:
a) NIL
1. Cardiovaskular sy stem
a) Normal
b) DRNM (dual rythm no murmur)
c) S1S2 normal with regular rythm
d) No chest pain while breathing
2. Respiratory system
a) Normal
b) Respiration rate – 22/min
c) Pulse rate – 77/min
d) No dyspnoea, no wheezing
e) No stridor
3. Circulatory system
a) Normal
b) No pale
c) No cyanose
d) No dizziness
e) No anaemia
4. Skeletal system
a) Normal
b) Positive motor reflex
c) Brudzinski sign negative
5. Exrectory sy stem
a) Normal
b) Bowel sound normal
c) Kidney palpable
6. Musculoskeletal sy stem
a) Normal
b) Muscle reflex positive
c) No muscle dystrophy
d) No tender or warm
7. Endocrine sy stem
a) Normal
b) No thyroid gland enlargement
c) No tremor
KHAS UNTUK PEDIATRIK:
Sejarah Kelahiran:
Sejarah Pemakanan:
Sejarah Tumbesaran:
IMUNISASI:
BCG DPT
Polio
+ Dos1
HepatitisBDos1 DPT+PolioDos2
HepatitisBDos2 DPT+PolioDos3
HepatitisBDos3 DPT+PolioBooster1
Campak DT+PolioBooster2
(Lain-lain imunisasi)
1. Pemeriksaan Am:
a) Head
i) Inspection
-normal
-no tumor
-no moon face
-no external skull
b) Ears
i) Inspection
-normal
-clean ; no discharge
-no bleeding
-no scar
c) Nose
i) Inspection
-normal
-clean
-no discharge
d) Eyes
i) Inspection
-normal
-no racoon
-no uprollingeyes
eyes
-symetrical and same size
ii) Palpation
-pink
-no jaundice
-dilate/reflex to light
-no periorbital pain
e) Mouth
i) Inspection
-normal
-pink
-not pale
-hydration fair
-no ulcer ; no bleeding
f) Neck
i) Inspection
-normal
-jugular vein normal
ii) Palpation
-no thyroid gland enlargement
-no trachea deviation
Bahagian Dada:
Jantung:
clear
1) Inspection
a) Normal
b) No scar
c) No wound/bleeding
d) No barrel chest
e) No deformiti
2) Palpation
a) Normal
b) No bone fracture
c) Apex beat normal
3) Percussion
a) Normal
b) No dullness sound
c) Resonance
4) Auscultation
a) Normal
b) No gallop sound
c) S1S2 normal
d) DRNM (dual rythm no murmur)
Paru-paru:
Lung clear
1) Palpation
a) Normal
b) Symetrical while breathing
2) Percussion
a) Normal
b) Resonance
3) Auscultation
a) Normal
b) No rhonki
c) No wheezing
d) No crepitus
e) Air entry equal bilateral
Abdomen:
Clear
1) Inspection
a) Normal
b) No scar
c) No any skin disease
2) Palpation
a) Normal
b) No scar
c) Bowel sound normal
3) Percussion
a) Normal
b) Dullness
4) Auscultation
a) Normal
b) Bowel sound heared
Sistem Saraf:
Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
1) Genital
a) Swelling 5cm × 5cm at right inguinal region, extending to scrotum
b) Tender
c) Not reducible
2) Rectum
a) Normal
b) No per rectum mass
c) No discharge
d) No rectum prolapse
e) No hemorrhoid
Scrotum is
growing and
tender
BAHAGIAN 5: DIAGNOSIS
Diagnosis sementara : Right inguinal hernia - based on the patient's main complaints,
and physical examination showed signs of inguinal hernia.
2) FBC ( Full blood count) - was performed to detect abnormalities in blood. These
tests were also conducted to detect whether the patient has medical conditions or
not. Example, Hb estimation test to see if an increase or decrease in hemoglobin
Result:
a) WBC (White blood cell) : 9.07×10^3 µL (5.2 – 12.4.)
b) RBC (Red blood cell) : 493×10^6 µL (4.50-5.50)
c) Hb (Haemoglobin) : 14.3 g/dL (13.0 -17.0)
d) Platelet : 271 x 10^3/uL (150-410)
Result:
a) Creatinine urea : 75 µmol/L
b) Sodium : 139 mmol/L (133-145)
c) Potassium : 3.9 mmol/L (3.5-5.4)
d) Chloride : 104 mmol/L (98-108)
Result:
a) The abdomen is normal.
5) Blood and Cross Matching (GXM)- to know the patient's blood to blood tranfer
done smoothly (if necessary)
Result:
a) Blood group : O
b) Rhesus factor : positive
BAHAGIAN 7: PENGURUSAN
Patients in the ward accompanied by his wife at about 8:23 am from emergency departmant
Hospital Sultanah Bahiyah (refferal case from Hospital Jitra).
1. Patient was received, and registered in record books.
2. Patients are placed in the room as the patient condition is not severe
3. Vital signs such as body temperature, blood pressure and respiratory rate were
recorded
4. Patients was rest in bed and taking patient history as the main com plaint, history
5. Patients undergoing general examination and physical examination (inspection,
percussion, palpation and auskultalsi)
6. Laboratory investigations were carried out as Full Blood Count (FBC), Blood Urea
Serum electrolyte (Buse), etc.
7. Provided health education to patients and patients waiting for surgery after getting a
diagnosis and was told by the nurse.
.
Preparation and Care of Patients Before Surgery (Pre Operative Care)
2. Patients should not make any heavy work to prevent incidents recurring hernia
3. Patients are encouraged to wear tight underwear
4. Patients are advised to reduce smoking because smoking can result in a patient
suffering from a cough that also can contribute to the occurrence of this hernia.
5. Patients should keep diet by eating foods that are nutritious and high in protein to
promote wound healing, such as fish
6. Patients are not allowed to apply water to prevent infection of surgical wounds in the
vicinity
7. Make sure that every doctor's appointment with a good compliance.
8. Patients should avoid emotional stress to speed up the healing process
9. Advise the patient to take care of personal hygiene.
Memuaskan
Lemah
Daripada ‘clerking case’ yang saya lakukan di wad kenanga 3C Hospital Sultanah
Bahiyah ini, banyak pembelajaran dan pengalaman baru yang saya perolehi. Antaranya ialah
saya berdepan dengan situasi sebenar pesakit yang betul dalam keadaan yang sakit dan
bagaimana cara untuk menangani situasi tersebut. Disamping itu, pesakit juga banyak
memberi kerjasama semasa mendapatkan riwayat pesakit, pengambilan sejarah dan
pemeriksaan fizikal. Saya juga dapat mengetahui lebih lanjut mengenai penyakit ingunial
hernia dan penyebabnya. Saya juga boleh melihat sendiri simtom-simtom yang dihadapi oleh
pesakit yang sebelum ini hanya mengetahui daripada teori semata-mata. Saya juga
berpeluang mempelajari dan mengendali pengurusan pra dan post-operative ini dalam
keadaan sebenar. Selain itu juga saya dapat mempraktikkan penjagaan kejururawatan yang
dipelajari di dalam kelas. Akhir sekali saya dapat mengetahui dan mengenali ubat-ubatan
digunakan dalam merawat kes yang berkaitan dengan penyakit ini seperti kaedah tindakan
ubat, dos, cara pemberian, interaksi ubat dan kesan sampingan ubat tersebut.