CASE CLERKING Format2.doc

CASE CLERKING

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:

Abdominal pain for 1 week

The patient was doing a medical check-up at Hospital Kota Tinggi at four o'clock in the afternoon. Doctors have been diagnosed intestinal obstruction disease. There, doctor said the patient should be referred to Hospital Sultan Ismail to get the full treatment. The patient was sent there by an ambulance.

Sejarah Penyakit Kini:

a) Patient was apparently all right 1 week ago when he developed abdominal pain

Generalised

Intermittent, colicky

No radiation of pain

b) Also associated with vomiting for the past 1 week

He claims that he vomits whatever he eats

Vomits food particles and fluids

No bile content

c) Loss of appetite ( LOA ) for 1 week

d) Abdominal distension for 1 week

e) Not reducing

f) Unable to BO for the past 4 days

Patient claims that he initially had diarrhea for the past 3 days

Then following that he had no more BO

But he still does pass flatus

Sejarah Penyakit Lalu:

(Termasuk alahan ubatan)

a) Allegic to seafoods

Sejarah Keluarga:

1. First son out of TWELVE ( 12 ) siblings

2. No history of malignancies among family members

Sejarah Sosial:

1. He smokes for more than 40 years

2. He is not an alcohol consumer.

3. He is non IVDU

4. He lives with wife and has FIVE ( 5 ) children

Sejarah O&G:

a) Nil

Sejarah Pembedahan Dahulu:

a) History of cataract operation for left eye

b) No other operations

KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1.Cardiovaskular system

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 20/min

c)Pulse rate 76/min

d)No dyspnea

e)No wheezing

f)No stridor

3.Circulatory system

a)Normal

b)No pale

c)No cyanose

d)No dizziness

e)No anaemia symptom

4.Skeletal system

a)Normal

b)Positive motor reflex

c)Brudzinski sign negative

5.Exrectory system

a)Bowel sound sluggish

c)Kidney palpable

6.Musculoskeletal system

a)Normal

b)Positive motor reflex

c)No muscle dystrophy

d)No tender or warm

7.Endocrine system

a)Normal

b)No thyroid gland enlargement

c)No tremor

KHAS UNTUK PEDIATRIK:

Sejarah Kelahiran:

None

Sejarah Pemakanan:

None

Sejarah Tumbesaran:

None

IMUNISASI:

Jenis ImunisasiTarikhJenis ImunisasiTarikh

BCGDPT + Polio Dos 1

Hepatitis B Dos 1DPT + Polio Dos 2

Hepatitis B Dos 2DPT + Polio Dos 3

Hepatitis B Dos 3DPT + Polio Booster 1

CampakDT + Polio Booster 2

(Lain-lain imunisasi)

BAHAGIAN 3: PEMERIKSAAN FIZIKAL

1. Pemeriksaan Am:

a)Mental status: alert

b)Orientation: people,time,place

c)Neuromotor: no seizures, no hemiparesis

d)Movement: able to move with mild pain

2. Tanda Vital

Penilaian kesakitan: 2/10

Suhu Badan: 37.0C

Kadar Pernafasan: 20 breaths per minute

Tekanan Darah: 140/71 mmHg

Kadar Nadi: 76 beats per minutes

Ritma Nadi: Regular

Berat Badan: 57 kg

Ujian Urin Glukosa: 8.3

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

-symmetrical 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:

1) Inspection

a) Normal

b) No scar

c) No wound / bleeding

d) No barrel chest

e) No deformity

2) Palpation

a) Normal

b) No bone fracture

c) Apex beat normal

3) Auscultation

a) Normal

b) No gallop sound

c) S1S2 normal

d) DRNM ( Dual Rythm No Murmur )

Paru-paru:

1) Palpation

a) Normal

b) Symmetrical while breathing

2) Percussion

a) Normal

b) Resonance

3) Auscultation

a) Normal

b) No rhonci

c) No wheezing

d) No crepitus

e) Air entry equal bilateral

Abdomen:

1) Inspection

a) Normal

b) No scar

c) No any skin disease

2) Palpation

a) Tense, generalised tenderness

b) Positive guarding

c) Positive rigidity

3) Percussion

a) Normal

b) Dullness

c) No shifting dullness

d) No fluid thrills

4) Auscultation

a) Bowel sound sluggish

Sistem Saraf:

1)Positive tendon reflex

2)Positive plantar reflex

3)Sensory function

4)Superficial touch normal

5)Pain when prick

Anggota Atas dan Bawah:

1)No deformiti

2)No clubing fingers

3)No varicose vein

4)Positive all movement (flexion, extension,abduction etc)

5)Hand dominance : Right

Lain-lain:

(termasuk Genitalia, Rektum dan sebagainya)

1)Genital

a)No swelling

b)Tender

c)Not reducible

2)Rectum

a)Normal

b)No per rectum mass

c)No discharge

d)No rectum prolapse

e)No hemorrhoid

BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

BAHAGIAN 5: DIAGNOSIS

Diagnosis Sementara:

Intestinal Obstruction

Diagnosis Perbezaan:

1. Acute Cholecystitis

2. Acute Apendicitis

3. Perforated Peptic Ulcer

4. Acute Pancreatitis

BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

RELEVAN

Blood Test:

1.) 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): 16.8010^3 L (5.2 - 12.4)

b)RBC (Red blood cell): 2.6310^6 L (4.50 - 5.50)

c)Hgb(Haemoglobin) : 14.5 g/dL (13.0 - 17.0)

d)Hct(Hematocrit): 19.4L/L (0.39 to 0.51)

e)Platelet : 339 x 10^3/uL (150-410)

2.) RP ( Renal profile) - detect any abnormalities of renal function

and to know the electrolyte balance in the body of the patient.

Result:

a)Creatinine urea: 99 mcmol/L (62-106)

b)Sodium: 135 mmol/L (135-145)

c)Potassium: 4.2 mmol/L (3.5-5.0)

d)Urea: 8.3 mmol/L (1.7-8.3)

3.) Abdominal X Ray to detect any abnormalities in the patient's abdomen

Result:

Dilated small bowel

BAHAGIAN 7: PENGURUSAN

Patient in the ward accompanied by his second and fifth daughter at about 7:00 pm from Emergency Departmant Hospital Sultan Ismail (refer case from Hospital Kota Tinggi). Patient was going through an operation Limited Right Hemicolectomy because patient was in the emergency condtion at the time when sent to the Emergency Department. The operation was done at about 8.00 pm.

1. Patient was admitted to be in male surgical ward 6A.

2. Patient was placed in the room as the patients condition which is not severe .

3. Patient was rest in bed and taking patient history as the main complaint, history.

4. Patients undergoing general examination and physical examination (inspection, percussion, palpation and auscultation).

5. Vital signs such as body temperature, blood pressure, pulse rate and respiratory rate were recorded.

6. Patient was admitted to be nil by mouth (NBM) and inserted intravena infusion with FOUR ( 4 ) pints, 2 Normal Saline, 2 Dextrose Saline.

7. Patient was kept in Ryles tube to be free flow and follow by FOUR ( 4 ) hourly aspirate.

8. Patient was observed for checking abdominal distension.

9. Laboratory investigations were carried out as Full Blood Count ( FBC ), Renal Profile ( RP ).

Preparation and Care of Patients Before Surgery (Pre Operative Care)

1. Describes the surgical procedure " laparotomy " advantages and

complications derived from patient.

2. Advising the patient not to worry to face surgery

3. Obtain consent from the patient or person responsible

4. Confirm written consent for the procedure from the patient or person responsible

5. Doing investigation Buse, Full Blood Count, and Diagnostic Imaging.

6. Prepare blood and Group Cross Match to replace a lot of blood in case of bleeding

7. Starve the patient as "Nil By Mouth" 6 hours before surgery

8. Intake of vital signs to ensure patient is in stable condition

9. Patient wears surgical gowns and oil cap

10. Send the patient to the operating theatre room (Dewan bedah)

Patient Care After Surgery (Post Operative Care)

1. Receive patient from the operating theatre room

2. Consuming vital sign every ONE ( 1 ) hour to monitor development as the first post-operative patient

3. Keep Nil By Mouth with Intravena Drip.

4. Do normal dressing three times a day ( TDS ) over the laparatomy wound

5. Patient is continued with antibiotics and trace tissue Culture & Sensitivity.

6. Patient is fully rest on the bed.

Treatment medications given

1. Patient was given medications such as:

IV Fentanyl 90mcg stat and OD

Action: acts as anesthesia and analgesic to patient.

Side effects: abdoment pain, agitation, constipation, headache, dry

mouth, vomiting

IV Morphine4mg

Action: acts as analgesics

Side efftects: constipation, itchy skin, headache, dizziness

Nursing care

a)monitoring vital signs of blood pressure, pulse and respiration and body temperature.

b)strictly observing and recording Input Output chart

c)observe and detect any bleeding

d)maintain patient in good comfortable and safety condition

e)maintenance of intravena infusion

f)patient hygiene as nails, hair, bowel and bladder

g)provide appropriate nutritional diet, High protein diet.

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Patient requires adequate rest to the healing of wounds due to surgery

2. Patient should keep diet by eating foods that are nutritious and high in protein to promote wound healing, such as fish

3. Patient is not allowed to apply water to prevent infection of surgical wounds in the vicinity

4. Make sure that every doctor's appointment with a good compliance.

5. Patient should avoid emotional stress to speed up the healing process

6. Advise the patient to do personal hygiene.

LAPORAN REFLEKTIF:

(Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah diperolehi daripada pengkajian kes ini)

Pengurusan kes:Baik

Memuaskan

Lemah

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini:

Saya praktikal di wad pembedahan di Hospital Sultan Ismail selama satu bulan. Saya mendapati bahawa terdapat banyak prosedur yang perlu dilakukan sebelum pembedahan, semasa pengendalian dan selepas pembedahan. Pesakit yang saya diambil sebagai kes clerking saya, dia dimasukkan wad dari 14 Februari hingga discaj pada 25 Februari 2014. Pesakit telah melalui right hemicolectomy, exploratomy laparatomy untuk stoma dan laparotomy untuk resection usus dan stoma. Saya belajar bahawa tidak ada cara mudah untuk menyembuhkan penyakit halangan usus tetapi ia boleh diketahui dengan menilai pemeriksaan dan siasatan setiap hari untuk mengetahui masalah perut dengan lebih lanjut.

KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE CLERKING

Nama Pelatih: No. Matrik: ..

Tahun: Semester: Kawasan Penempatan: ...

Bil.

Perkara

Wajaran

Skor

Catatan

1

Keterangan Peribadi Pesakit

5

2

Riwayat Pesakit:

2.1 Aduan Utama

2.2 Sejarah Penyakit Kini

2.3 Sejarah Penyakit Lalu

2.4 Sejarah Keluarga

2.5 Sejarah Sosial

(Lain2 yang berkenaan)

25

3

Pemeriksaan Fizikal:

3.1 Pemeriksaan Am

3.2 Tanda-tanda Vital

3.3 Kepala & E/ENT

3.4 Dada (Jantung)

3.5 Dada (Paru-paru)

3.6 Abdomen

3.7 Sistem Saraf

3.8 Anggota Atas & Bawah

3.9 Lain-lain (seperti genitalia & rektum, dll)

(Mana2 yang berkenaan)

25

4

Ringkasan Penemuan Klinikal

5

5

Diagnosis:

5.1 Diagnosis Sementara

5.2 Diagnosis Perbezaan

5

6

Penyiasatan Yang Penting & Relevan

5

7

Pengurusan:

7.1 Pengendalian awal

7.2 Ubat-ubatan

7.3 Penjagaan kejururawatan

20

8

Pendidikan Kesihatan

5

9

Laporan reflektif

5

JUMLAH

100

Tandatangan Pemeriksa: .

Nama: .

Tarikh:

KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK CASE PRESENTATION

Nama Pelatih: No. Matrik: ....

Tahun: Semester: Kawasan Penempatan: .......

Bil.

Perkara

Wajaran

PELAKSANAAN

Skor

Catatan

Baik

Memuaskan

Lemah

1

Pembentangan keterangan peribadi pesakit yang tepat

1

2

Pembentangan riwayat pesakit yang lengkap

2

3

Melakukan pemeriksaan fizikal yang lengkap dan relevan dengan betul

3

4

Pembentangan diagnosis & diagnosis perbezaan yang tepat

1

5

Cadangan penyiasatan yang penting & relevan

1

6

Pembentangan pengurusan pesakit yang tepat dan lengkap

2

JUMLAH

10

Skor: ......... x 100% = ..........................%

10

Tandatangan Pemeriksa: .

Nama: .

Tarikh:

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