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CASE CLERKING
NAMA PELATIH NO. MATRIK NO. KAD PENGENALAN TAHUN / SEMESTER KAWASAN PENEMPATAN
: MOHD EIZAIRIE BIN ABDUL MUTALIB : DBMA11-6071 : 910709-04-5023 :2/2 : WAD 3C (PEMBEDAHAN) HOSPITAL SULTANAH BAHIYAH , ALOR SETAR, KEDAH DARUL AMAN
KURSUS DIPLOMA PEMBANTU PERUBATAN CASE CLERKING Nama Pelatih No. Matrik Tahun Kawasan Penempatan : MOHD EIZAIRIE BIN ABDUL MUTALIB : DBMA11-6071 : 2 Semester : 2
BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT Nombor Pendaftaran: AS 00330537 Nombor K/P: -TIDAK PERLUNama: -TIDAK PERLU DIISI Jantina: Lelaki/ Perempuan* : LELAKI Alamat: -TIDAK PERLUHospital/Klinik: HOSPITAL SULTANAH BAHIYAH Bangsa: MELAYU Pekerjaan: JURUTEKNIK ALARM Umur: 29 THN No. Tel: -TIDAK PERLUTarikh:
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
d) The patient has not had a contagious disease (penyakit berjangkit) e) The patient has never had a kidney and urinary disease
f) The patient is not suffering from the disease Diabetes Mellitus
2. Father
i) NIL
Sejarah Sosial:
a) He has married to Nordina, 27 years old
b) He got 1 children and he was healthy c) Work as alarm engineer at Indah Water
Sejarah O&G:
a) NIL
KHAS UNTUK PEDIATRIK: Sejarah Kelahiran: Sejarah Pemakanan: Sejarah Tumbesaran: IMUNISASI: Jenis Imunisasi BCG Hepatitis B Dos 1 Hepatitis B Dos 2 Hepatitis B Dos 3 Campak (Lain-lain imunisasi) Tarikh Jenis Imunisasi DPT + Polio Dos 1 DPT + Polio Dos 2 DPT + Polio Dos 3 DPT + Polio Booster 1 DT + Polio Booster 2 Tarikh
3. Pemeriksaan Kepala dan Sistem Deria Khas: (termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)
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 eyes -no uprolling 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
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)
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:
1) 2) 3) 4) 5) Positive tendon reflex Positive plantar reflex Sensory function Superficial touch normal Pain when prick
Note : Patient was able to move all fingers and the capillary refill is less than 2 seconds,
sensation intact.
BAHAGIAN 5: DIAGNOSIS Diagnosis sementara : Right inguinal hernia - based on the patient's main complaints,
and physical examination showed signs of inguinal hernia.
Diagnosis Perbezaan: -
BAHAGIAN 6:
1) Patient is asked to cough to see how the bumps (bonjolan). 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) b) c) d)
WBC (White blood cell) RBC (Red blood cell) Hb (Haemoglobin) Platelet
: 9.0710^3 L (5.2 12.4.) : 49310^6 L (4.50-5.50) : 14.3 g/dL (13.0 -17.0) : 271 x 10^3/uL (150-410)
Result:
a) Creatinine urea b) Sodium c) Potassium : 75 mol/L : 139 mmol/L (133-145) : 3.9 mmol/L (3.5-5.4) : 104 mmol/L (98-108)
d) Chloride
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 complaint, 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.
. Patient Care After Surgery (Post Operative Care) 1. Receive patients from the operating theater
2. Consuming vital sign every 15 minutes, then every hour and 2 hours to monitor development as the first post-operative patients 3. 3 pint Infuse Normal Saline 0.9% intravenously to prevent dehydration 4. Observations on the surgery 2 times a day
5. Patients are allowed to eat by mouth after fully realized with a soft diet
Tramal capsules 50 mg TDS for 5 days Action Side effects : This narcotic type drugs act to reduce the pain experienced by patients after surgery. : constipation, nausea, dizziness, vomiting and weak pulse.
1. Patients require adequate rest to the healing of wounds due to surgery 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. 10. Do refer to hospital if there are complications
LAPORAN REFLEKTIF: (Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah diperolehi daripada pengkajian kes ini) Pengurusan kes: Baik Memuaskan Lemah