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CASE CLERKING

Nama Pelatih

: Muhamad Suhaimi Bin Ahmad Juhari

No. Matrik

: BPP 2005 - 0530

No. i/c

: 850412-07-5393

Wad

: Unit Perubatan ( X1 )

Hospital

: Hospital Alor Setar.

Nama pesakit

: Tunku Hardi Bin Tunku Mohd Shukri

No i/c

: 650216-02-5309

Warganegara

: Malaysia

Umur

: 41 thn

Jantina
.
Alamat

: Lelaki, Melayu
: No 54 Kampung Kuala,
08200 Sik, Kedah.

R/N

: 502900

-----------------------------------------------------------------------------------------------------------Pengesahan ketua unit di penempatan klinikal dan penyelia pelatih


Tandatangan

:.........................................

Nama

:........................................

Jawatan

:........................................

Tarikh

:........................................

Nama Penyelia

:........................................

T/Tangan

:.

Tarikh Penyerahan :.....

*Refer from A&E Department


Hospital Alor Setar.
C/O

: Pain at left leg x 1/52.

HOPI : -Become pain at left leg when walking x 1/52


-Came with mild pain at the left leg at casualty Hospital Alor Star
yesterday.
- Loss of appetite x 2/7
- No lost of weight
- No fever
-No accident history
- Become swelling at left leg x 3/7
PMH : - Known case as Hypertension.
- No history of Diabetes mellitus
- His father have hypertension and passed away 5 year ago.
PSH : -No significant
Family history : -

Patient

Social History
- Smoking
- No Alcohol Consumption.
- Work as businessman at sungai petani.
- Monthly Salary around RM900-RM1000
On Examination:
Genaral Condition : - Patient Alert & Concious

-B/P:

132/71

- Pink, No pallor, No Joundice.

-Pulse: 45/minute

- Skin pinch Normal-

-R/R : 40/minute
-Temp:37 c

Head Examination : - Normal,No Head Injury


Eye : - No Blured Vission,No diplopia.
Nose : - No Discharge,No Epitaxis.
Ear : - No Discharge,No Tinnitus,No Vertigo
Throat :- No Sorethroat,Tonsil not enlarge.
FIZICAL EXAMINATION :
Neck examination:
-Inspection : No Scar, no wound and no torticollis
-Palpation

: No trachea deviated, no nodules, or no tenderness of


Thyroiditis.

Cardiovascular system
-Inspection

: No cyanosis, normal breath rate.

-Percusion

: Nil ( Normal ).

-Palpation

: Mid Sharf Clavicle 5th Intercostal Space. ( Apex Beat ).

-Auscaltation : Dual Rythm No Murmur ( DRNM ) Apex Beat : 80 / min.


Respiratory system
-Inspection

: Pengembangan dada : Bilateral ( 17 / min ).

-Percusion

: Resonance.

-Auscaltation

: Air Entry equal bilateral, no Crep and no Rhonci.

clear

Abdomen examination:
Inspection

- Normal.
- No striae.

Palpation

- Soft.
- No mass.
- No tenderness.
- No Organomegali.

Percussion

- Resonance.

Auscultation

- Bowel sound positive.

Kidney,hepar and spleen


Soft, not distended

Central nerves system :


Inspection

- patient allert ( GCS 15 / 15 ).

Sensory nerves

- non abnomality ditected.

Motor nerves

- able to move.

Per rectum :
-Good anal tone.
-No mass at anal region.
-Prostate enlarged ( moderate to servere

Leg Examination:
Kaki kanan
Inspection:
- No trauma or injuries found
- No abnormalities found
Palpation:

No tender
No Swelling
No infection.

Pemeriksaan Spesifik
Kaki kiri:
Inspection:
- Swelling at left leg
- No discharge
- Seen redness.
- Mampu menggerakkan
Palpation:
- Tender bahagian posterior
- No loss of pulses

semua jari kaki


tibia

Per rectum :
-Good anal tone.
-No mass at anal region.
-Prostate enlarged ( moderate to servere ).
Investigation:
Reflolux test: 7.1mmol/L (Normal: 3.8-10.0 mmol/L)
- BUSE -Urea 35.16 (Normal 1.7-8.2mmol/L)
-Sodium 136.82 (Normal 135-152 mmol/L)
-Pottasium 4.9mmol/L (Normal 3.5-5.4 mmol/L)
-Chloride 101.9 (Normal 9.6-10.8 mmo/L)
Full Blood Count
Bagi menilai Total White Different Count(TWDC)
White blood count 21.7mmol
(Abnormal white blood cell) julat normal 5.2-12.4 mmol
Red blood cell 4.7 mmol. Julat normal 4.2-5.4mmol
Platelet 4100mmol.julat normal 4000-11000mmol

- VBG

- PH - 7.28 (Normal 7.35-7.45ph)


- Pco2 - 30/mmHg (Normal 35.00-45.00mmHg)
- Po2 - 63.7 mmHg (Normal 80-90 mmHg)
- Actual Bicarbonate: 14.1mmol/L (Normal 2226mmol/L)

Sr.Creatinane :- 1889.0 mmol/L (Normal 53-106 mmol/L)

ECG : T inversion 1,2.AVL,V5,V6 No Ischemic.

Diffrential Diagnose:
-Eczema
-Pemphigus
-cellulitis
Diagnose:
Cellulitis
Plan for treatment :

- Rest in bed
-infusion intravenous stat antibiotic unasyn 1.5 gram
-infusion intravenous normal saline 0.9% maintanence
-Infusion intravenous Tramal 50 mg prn.
-Vital Sign: B/P,Pulse,Temp,R/R 4 Hourly
-Monitor Intake & Output Chart.
-Encourage for Therapeutic Diet.
-Drug : -Tab.Lovastatin 20mg ON- CVS> For reduce
cholestrol
-Tab.Metoprolol 100mg BD- Anti Hipertension.