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Case Clerking Hernia
Case Clerking Hernia
NAMA PELATIH
NO. MATRIK
: DBMA11-6071
: 910709-04-5023
TAHUN / SEMESTER
:2/2
KAWASAN PENEMPATAN
: WAD 3C (PEMBEDAHAN)
HOSPITAL SULTANAH BAHIYAH , ALOR
SETAR, KEDAH DARUL AMAN
No. Matrik
: DBMA11-6071
Tahun
: 2
Kawasan Penempatan
Semester
: 2
Nombor K/P:
-TIDAK PERLU-
Nama:
-TIDAK PERLU DIISI Jantina: Lelaki/
Perempuan* :
LELAKI
Bangsa:
MELAYU
Pekerjaan:
JURUTEKNIK
ALARM
Umur:
29 THN
Alamat:
No. Tel:
-TIDAK PERLU-
-TIDAK PERLU-
Hospital/Klinik:
HOSPITAL SULTANAH BAHIYAH
Tarikh:
MASUK WAD:
17-01-2013 @
8.23 AM
KELUAR WAD:
19-01-2013 @
9.10 AM
g) No h/o trauma
h) No h/o insect bite to the affected area
Sejarah Keluarga:
1. Mother
i)
NIL
2. Father
i)
NIL
Sejarah Sosial:
a) He has married to Nordina, 27 years old
b) He got 1 children and he was healthy
Sejarah O&G:
a) NIL
Tarikh
Jenis Imunisasi
BCG
Hepatitis B Dos 1
Hepatitis B Dos 2
Hepatitis B Dos 3
Campak
DT + Polio Booster 2
(Lain-lain imunisasi)
: aware,not confused
b) Orientation
: people,time,place
c) Neuromotor
: no seizures, no hemiperasis
d) Movement
: 2/10
Suhu Badan
: 37C
Kadar Pernafasan
: 22
Tekanan Darah
:128/74 mmHg
Kadar Nadi
: 77/min
Ritma Nadi
: Regular
Berat Badan
: 70 kg
Tarikh
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:
1)
2)
3)
4)
5)
No deformiti
No clubing fingers
No varicose vein
Positive all movement (flexion, extension,abduction etc)
Hand dominance : right
Note : Patient was able to move all fingers and the capillary refill is less than 2 seconds,
sensation intact.
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.
Diagnosis Perbezaan: -
3. Spermatocele
BAHAGIAN 6:
Result:
a)
b)
c)
d)
Result:
a) Creatinine urea
b) Sodium
c) Potassium
: 75 mol/L
: 139 mmol/L (133-145)
: 3.9 mmol/L (3.5-5.4)
d) Chloride
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 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.
.
Preparation and Care of Patients Before Surgery (Pre Operative Care)
1. Describes the surgical procedure "right hernioplasty" advantages and
complications derived from patients
2.
.
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
6. Patients fully rest on the bed
Action
Side effects
Side effects
LAPORAN REFLEKTIF:
(Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah
diperolehi daripada pengkajian kes ini)
Pengurusan kes:
Baik
Memuaskan
Lemah