KURSUS DIPLOMA PEMBANTU PERUBATAN
CASE CLERKING
Nama Pelatih : MOHAMAD FAKRULLAH BIN MOHD AZLIN
No. Matrik : BPP2019-0173
Tahun :2 Semester :4
Kawasan Penempatan : HOSPITAL TEMENGGONG SRI MAHARAJA TUN
IBRAHIM
BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT
Nombor Pendaftaran: Nombor K/P:
-TIDAK PERLU DIISI -
Nama:
-TIDAK PERLU DIISI -
Jantina: Lelaki/ Bangsa: Pekerjaan: Umur:
Perempuan*
Alamat: No. Tel:
-TIDAK PERLU DIISI - -TIDAK PERLU
DIISI -
Hospital/Klinik: Tarikh admit:
BAHAGIAN 2: RIWAYAT PESAKIT
Aduan Utama:
1. Chest pain over 1/7 last night
2. Headache for 1/52
3. Nause and vomiting
Sejarah Penyakit Kini:
1. No medical was reported
Sejarah Penyakit Lalu:
(Termasuk alahan ubatan)
1. No allergies of medication
2. No past surgery
Sejarah Keluarga:
1. Live with his family at Senai
2. Has 3 children
3. His mother has myocardial infarction
Sejarah Sosial:
1. Activer smoker
2. No alcoholism
3. Work at factory as a supervisior
Sejarah O&G:
None
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:
I) Cardiovascular system (CVS)
-no murmur
- pulse rate is 107 /min during rest
-pulse rhytm is irregular
II) Respiratory system
- no shortness of breath
- respiratory rate 24/min when chest pain
-uneven air intake
- sounded normal
III) Nerve system
- Plantar reflex positive
- tendon reflex positive
-skin sensation positive
IV) Endocrin system
-there are no abnormalities in thyroid gland
-no hepatomegaly
V) Musculosceletal system
- movement upper body and lower body normal
- patient was able to walk
VI) Genito Urinary system
- no change for urinations habit
-no discoloration in urine
- urine production was normal
VII) Alimentary system
- diffcult to swallow food
- no constipation
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
Pemeriksaan Am:
I) Patient was concious and stable
II) Patient can speak normal and clearly
Date :22.6.2021
Time :10:45 a.m.
Tanda Vital:Glasgow Coma Scale(GCS) Eye= 4 Verbal=5 Motor=6
Penilaian kesakitan: Pain Score = 3
Suhu Badan: 36.5 Kadar Pernafasan:19 Tekanan Darah:140/95
Kadar Nadi:96 Ritma Nadi:Irregular Isipadu Nadi:Kuat
Berat Badan: 87kg Ujian Urin Glukosa:- Albumin:-
Pemeriksaan Kepala dan Sistem Deria Khas:
(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)
I) Head
- no any cut or scar
-no swelling
II) Ear
-normal and patient can hear well
- no discharge or bleeding
- no swelling or pain
III) Eye
-normal
- no redness or jaundice
-no strabismus or cataract
IV) Nose
-normal and no scars or cuts
- no swelling or pain
V) Mouth
- normal and no scars or cuts
- odorless breathing
Bahagian Dada:
Jantung:
I)Inspection
-no scars
- no skeletal defect such as pigeon chest or barrel chest
II)Palpation
- no chest pain
- asymetrical chest movement
III)Auscultation
- no murmur
-apecs rhtym 97/min
Paru-paru:
I) Inspection
- no scars
- no abnormalities
II) Palpation
- no swelling
- normal chest movement
III)Percussion
-sounded ressonant
IV)Auscultation
-no crepitus
-no rhonci or stridor
Abdomen:
-No abdominal distension
-No color change
-No surgical scars
II)Palpation
-no pain or swelling
-soft
III)Percussion
-normal sound: resonans
IV)Auscultation
- normal bowel sound
Sistem Saraf:
-Positive reflex tendons
-Plantar positive reflex
-Positive biceps and triceps muscle movements when tested with hammer tendons
-Normal sensation i.e. the patient feels pain when pricked with a needle
Anggota Atas dan Bawah:
I)Pelvic
Inspection:
-no scar
Palpation
- no swelling or oedema
-no fracture
Anggota Atas
I)Inspection:
-no fractures
-no injuries
II)Palpation:
-no swelling
-can perform flexion, extension, circulation, abduction, adduction and rotation
normally
Anggota Bawah
I)Inspection
-no abnormalities
II)Palpation
-can perform flexion, extension, circulation, abduction, adduction and rotation
normally
Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
i.Genetelia
-Normal
-Normal urine excretion
-No discharge coming out of the patient's genitals
-No hematuria
ii.Rectum
-Normal
-Normal and regular bowel movements
-No bleeding and discharge coming out of the patient’s anus
-No melena stool
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN
BAHAGIAN 5: DIAGNOSIS
Diagnosis Sementara/ tepat:
Myocardial Infarction
Diagnosis Perbezaan:
1.Angina Pectoris
2.Syncope
3. Congestive Cardiac Failure
4. Myocardial Infarction
5.Acute Myocardial Infarction
BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN
RELEVAN
1. Full blood count (FBC)
White blood cell : 13.6 (normal range: 4.0-10.0x10)
Haemoglobin : 13.5 (normal range: 11.5-16.0g/dl)
Platelet : 277 (normal range: 150-400x10 9/l)
2. Urine Full Microscopic Examination ( Urine FEME)
Leucocyte : negative
Nitrate : negative
RBC : negative
Protein : negative
Ketone : negative
Bile : negative
3. Electro Cardiogram (ECG)
- ST Elevation
4. Glucometer
- Normal Range 6.8 mmol/L ( less than 140mg/dL 7.8 mmol/L)
5. Echocardiogram
- RV is infarcted, RV dilation, RV segmental wall motion abnormalities
BAHAGIAN 7: PENGURUSAN
1.Management in Emergency Department
I)Take the patient's main complaint to identify the temporary diagnosis experienced
by the patient
II)Set IV line to facilitate procedures such as blood collection, medication and to
drain IV drips while the patient is in the ward
III)Take blood and urine for testing to check for the presence of infection and identify
disease
IV)Medication administration Tab. Tramadol 25 mg to patients to prevent chest pain.
V) refers patient to the medical ward .
2. Management in Medical Ward
I)Rest the patient in bed
II)Take vital signs such as blood pressure, body temperature, pulse rate and
respiratory rate of the patient
III)Give intravenous infusion i.e. IV drip 5 ּסi.e. 3 ּסNormal Saline and 2 ּסDextrose
5% (when needed) as directed by the doctor
IV) oxgyen provided to control level of oxygen
IV)Patients are instructed to fast to perform ECG.
V) Giving medicines such as:
IV Diamorphine 2.5-5mg (repeatedas necessary)
Tablet Diazepam 2-5 mg orally
Tablet Glyceryl Trinitrate 0.5 mg sublingually
vi. Conduct investigations such as taking full blood count, urine FEME and BUSE
4) Nursing Care
i.Monitor vital signs and chart patient input and output
ii. Personal hygiene of the patient.
iii. Care of the patient's food which is food high in protein
iv.Always provide emotional support to the patient to speed up the patient's recover
v. Giving medicines as directed by the doctor
vi.Continue monitoring ECG
vii.Giving TCA ( To Come Again) for futher investigation
BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA (berkenaan
dengan penyakit yg dikaji)
i. Life style habit.
- slowly stop smoking
ii.Nutrition
- Consume nutritious foods or high in protein, vitamins and vegetables and fruits. It is
to promote to healthy life style
iii.Exercise
- Perform exercises or activities that suit the patient's ability
iv.Follow -up treatment
-Patients should come on the day of follow -up treatment as prescribed by the
doctor. -It is to assess the patient’s pain level and to make sure the patient is in good
health
v.Medications
-Take medicine as directed by the doctor
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:
By doing a case study of this disease, I can see for myself the symptoms of this
disease and can find out about the investigation whether routine or specific. It can
equip us to perform IPPA procedures.Through the study of this disease, I was able
to learn about the handling in the surgical ward that is about the initial handling
during admission to the ward, the treatment given, medications and also nursing
care. It is more specific than what is obtained in lectures.
KURSUS DIPLOMA PEMBANTU PERUBATAN
FORMAT PEMARKAHAN CASE CLERKING
Nama Pelatih: MOHAMAD FAKRULLAH BIN MOHD AZLIN
No. Matrik: BPP2019-0173
Tahun: 2 Semester: 4 Kawasan Penempatan: HOSPITAL KULAI
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 25
2.4 Sejarah Keluarga
2.5 Sejarah Sosial
(Lain2 yang berkenaan)
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) 25
3.6 Abdomen
3.7 Sistem Saraf
3.8 Anggota Atas & Bawah
3.9 Lain-lain (seperti genitalia & rektum, dll)
(Mana2 yang berkenaan)
4 Ringkasan Penemuan Klinikal 5
5 Diagnosis:
5.1 Diagnosis Sementara
5
5.2 Diagnosis Perbezaan
6 Penyiasatan Yang Penting & Relevan 5
7 Pengurusan:
7.1 Pengendalian awal
20
7.2 Ubat-ubatan
7.3 Penjagaan kejururawatan
8 Pendidikan Kesihatan 5
9 Laporan reflektif 5
JUMLAH 100
Tandatangan Pemeriksa : ……………………………….……………
Nama : …………………………….………………
Tarikh : ……………………………………………
KURSUS DIPLOMA PEMBANTU PERUBATAN
SENARAI SEMAK CASE PRESENTATION
Nama Pelatih: MOHAMAD FAKRULLAH BIN MOHD AZLIN
No. Matrik: BPP2019-0173
Tahun: 2 Semester: 4 Kawasan Penempatan: HOSPITAL KULAI
PELAKSANAAN
Bil. Perkara Wajaran Memuas Skor Catatan
Baik Lemah
kan
Pembentangan
1 keterangan peribadi 1
pesakit yang tepat
Pembentangan riwayat 2
2
pesakit yang lengkap
Melakukan pemeriksaan
3
3 fizikal yang lengkap dan
relevan dengan betul
Pembentangan
1
4 diagnosis & diagnosis
perbezaan yang tepat
Cadangan penyiasatan
5 1
yang penting & relevan
Pembentangan
2
6 pengurusan pesakit yang
tepat dan lengkap
JUMLAH 10
Skor: …….........… x 100% = ..........................%
10
Tandatangan Pemeriksa : ……………………………….……………
Nama : …………………………….………………
Tarikh : ……………………………………………
