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KURSUS DIPLOMA PEMBANTU PERUBATAN
CASE CLERKING
Nama Pelatih : MUHAMMAD AMIRUL AMMAR BIN RAZALLI
No. Matrik : BPP 2011-5995
Tahun : 3 Semester : 2
KawasanPenempatan : WAD PAEDIATRIK 8A, HTJS
BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT
NomborPendaftar
HTJ 553230
Nombor K/P:
-TIDAK PERLU DIISI -
Nama:
ALICTER NATASHA ANAK ISOP
Jantina:
PEREMPUAN
Bangsa:
IBAN
Pekerjaan:
-
Umur:
1 BLN 18 HARIAlamat:
-TIDAK PERLU DIISI -
No. Tel:
-TIDAK PERLU DIISI -
Hospital/Klinik:
HOSPITAL TUANKU JAAFAR, SEREMBAN
Tarikh:
BAHAGIAN 2: RIWAYAT PESAKIT
AduanUtama:
Ibu mengadu pesakit mengalami ‘unconsolable cry’ pada hari ini.
SejarahPenyakitKini:
Fever two days ago with high grade fever, on and off sudden on set.
Vomitting once episode at 6pm yesterday. Only food particles included.
No chills and rigors
No rashes
Mild tacypnoea
Claimed tolerate orally well (breastfeeding)
No weight loss
No bleeding tenderness
SejarahPenyakitLalu:
(Termasukalahanubatan)
No history of allergy in foods or any drugs
SejarahKeluarga:
Parent have 2 children
Patient is the youngest in the family
SejarahSosial:
Both parent were sarawakian, works in plastic factory at Senawang
They lives in tamanSeremban Jaya
No dengue fever cases in living area
No recent travelling
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:
1.Sistem Kardiovaskular
Normal apex beat location in space between of intercostal 5th and 6th
Apex beat normal 148/min
normal sinus rhtym
2.Sistem Respiratori
normal breathing
no wheezing
no krepitasion
no hiperresonan
no dullnes
3.Sistem Pertumbuhan
gross motor : patient can move all four limbs
fine motor : patient able ti grab mother’s finger
speech : crying, laughing
4.Sistem Genitourinari
no dysuria
no hematuria
BO normal
PU normal
5.Sistem Endokrina
No abnormalities at tyroid gland
No signs of moonface
No distension abdominal
KHAS UNTUK PEDIATRIK:Sejarah Kelahiran:
Patient was delivered by Spontaneous Vaginal Delivery (SVD)
There is no complication during the delivery
Sejarah Pemakanan:
Breast feeding 60cc per intake 3 hourly/day
IMUNISASI
JenisimunisasiTarikh
BCG 2/8/2007 DTap + Hib + IPV 1 2/10/2007 DTap + Hib + IPV 2 3/11/2007 DTap + Hib + IPV 3 7/1/2008 DTap + Hib + IPV Booster 5/2/2009 MMR 3/8/2008 Hepatitis B Dos 1 2/8/2007 Hepatitis B Dos 2 2/9/2007 Hepatitis B Dos 3 12/2/2008
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
Pemeriksaan Am:
Tanda Vital:GCS = 15/15
Suhu Badan: 38.5 c Kadar Pernafasan: 32/minit Tekanan Darah: 65/40
KadarNadi: 148/minit Ritma Nadi: regular IsipaduNadi: good
Berat Badan: 3.8 kg Ujian Urin Glukosa: - Albumin: -
Pemeriksaan Kepala dan Sistem Deria Khas:
(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)
Mulut:
Inspeksi – no ulser,dehydrated
Palpasi – no swelling/oedema
Tekak:
Inspeksi – red spot area of uvula
Palpasi – no tonsilitis
Telinga:
Inspeksi – normal shape,good hearing and no discharge
Palpasi – no swelling
Hidung:
Inspeksi – normal shape, no discharge, no scar, breathing airway clear
Palpasi - no swelling and tenderness
Mata:
Inspeksi – normal, no jaundice, no anaemia
Palpasi:-intra occular pressure normal
Leher:
Inspeksi – both left and right side parallel
Palpasi – no enlargement of tyroid gland
Kepala:
Inspeksi – no scalp scar, normal shape
Palpasi – no haematoma
Bahagian Dada:
Jantung:
Dual Rythm No Murmur ( DRNM )
Inspeksi – normal chest shape
- both chest simetricle
- no scar
palpasi – apex beat 148/minit
- Normal apex beat location in space between of intercostal 5th and 6th
Perkusi – no hiperresonan.
Auskultasi - DRNM ( normal )
- regular pulse rythm
-Chest Spring -ve
Paru-paru:
Inspeksi – normal shape, no pigeon chest
- both chest simmetricle when air entry equally
- no scar
Palpasi - no tenderness in both side
perkusi - no hiperresonan in both chest
- No dullness
Auskultasi – no ronki
- no krepitasion
- no wheezing sound heard
Abdomen
Inspeksi – no scar and tenderness
Palpasi - no tenderness at epigastric, soft and no ascites