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KURSUS DIPLOMA

KOLEJ PEMBANTU
PEMBANTU PERUBATAN
PERUBATAN
ALOR SETAR

CASE CLERKING

TAJUK : RIGHT INGUINAL HERNIA

NAMA PELATIH : MOHD EIZAIRIE BIN ABDUL MUTALIB


NO. MATRIK : DBMA11-6071
NO. KAD PENGENALAN : 910709-04-5023
TAHUN / SEMESTER :2/2
KAWASAN PENEMPATAN : WAD 3C (PEMBEDAHAN)
HOSPITAL SULTANAH BAHIYAH , ALOR
SETAR, KEDAH DARUL AMAN
KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih : MOHD EIZAIRIE BIN ABDUL MUTALIB

No.Matrik :DBMA11-6071

Tahun :2 S emester :2

Kawasan Penempatan : HOSPITAL SULTANAH BAHIYAH

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: AS 00330537 Nombor K/P:

-TIDAK PERLU-

Nama:

-TIDAK PERLU DIISI -

Jantina: Lelaki/ Bangsa: Pekerjaan: Umur:


Perempuan* : MELAYU JURUTEKNIK 29 THN
LELAKI ALARM

Alamat: No. Tel:

-TIDAK PERLU- -TIDAK PERLU-

Hospital/Klinik: Tarikh:
HOSPITAL SULTANAH BAHIYAH MASUK WAD:
17-01-2013 @
8.23 AM
KELUAR WAD:
19-01-2013 @
9.10 AM
BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:
a) Patients have complained of bumps in his scrotum
b) Bumps more prominent (kelihatan) and growing.
c) Noticed around 8 pm last night (16/01/2013)
d) Referred case from Hospital Jitra for irreducible right inguinal hernia

Sejarah Penyakit Kini:


a) irreducible of the right inguinal hernia
b) able to BO (bowel open) and pass flatus
c) no vomiting
d) swelling increase in size (5cm × 5 cm)
e) otherwise no other symptom
f) PU (pass urine) normal ; no dysuria
g) No h/o trauma
h) No h/o insect bite to the affected area

Sejarah Penyakit
(Termasuk alahanLalu:
ubatan)

a) No known allergy to food or any drugs


b) Not taken any traditional drugs or treatment
c) The patient has never had a respiratory problem
d) The patient has not had a contagious disease (penyakit berjangkit)
e) The patient has never had a kidney and urinary disease
f) The patient is not suffering from the disease Diabetes Mellitus

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
c) Work as alarm engineer at Indah Water
d) He is social smoker (+/- 5 cigarette per day)
e) He is non alcoholic

Sejarah O&G:
a) NIL

KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1. Cardiovaskular sy stem
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 – 22/min
c) Pulse rate – 77/min
d) No dyspnoea, no wheezing
e) No stridor

3. Circulatory system
a) Normal
b) No pale
c) No cyanose
d) No dizziness
e) No anaemia

4. Skeletal system
a) Normal
b) Positive motor reflex
c) Brudzinski sign negative

5. Exrectory sy stem
a) Normal
b) Bowel sound normal
c) Kidney palpable

6. Musculoskeletal sy stem
a) Normal
b) Muscle reflex positive
c) No muscle dystrophy
d) No tender or warm

7. Endocrine sy stem
a) Normal
b) No thyroid gland enlargement
c) No tremor
KHAS UNTUK PEDIATRIK:

Sejarah Kelahiran:

Sejarah Pemakanan:

Sejarah Tumbesaran:

IMUNISASI:

Jenis Imunisasi Tarikh Jenis Imunisasi Tarikh

BCG DPT
Polio
+ Dos1

HepatitisBDos1 DPT+PolioDos2

HepatitisBDos2 DPT+PolioDos3

HepatitisBDos3 DPT+PolioBooster1

Campak DT+PolioBooster2

(Lain-lain imunisasi)

BAHAGIAN 3: PEMERIKSAAN FIZIKAL

1. Pemeriksaan Am:

a) Mental status : aware,not confused


b) Orientation : people,time,place
c) Neuromotor : no seizures, no hemiperasis
d) Movement : able to move with mild pain

2. Tanda Vital: (taken at 17/01/2013 @ 9.30 am)

Penilaian kesakitan : 2/10


SuhuBadan :37°C
Kadar Pernafasan : 22
Tekanan Darah :128/74 mmHg
KadarNadi :77/min
RitmaNadi :Regular
BeratBadan :70kg
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
-no uprollingeyes
eyes
-symetrical 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:

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) 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
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

BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

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: - 1. Hernia femoralis ( contain bowel)


2. Incomplete Descending Testis
3. Spermatocele
BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN
RELEVAN

1) Patient is asked to cough to see how the bumps (bonjolan).

2) 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) : 9.07×10^3 µL (5.2 – 12.4.)
b) RBC (Red blood cell) : 493×10^6 µL (4.50-5.50)
c) Hb (Haemoglobin) : 14.3 g/dL (13.0 -17.0)
d) Platelet : 271 x 10^3/uL (150-410)

3) 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 : 75 µmol/L
b) Sodium : 139 mmol/L (133-145)
c) Potassium : 3.9 mmol/L (3.5-5.4)
d) Chloride : 104 mmol/L (98-108)

4) X-ray – to detect any abnormalities in the patient's abdomen

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 com plaint, 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. Advising patients not to worry to face surgery
3. Obtain consent from the patient
4. Doing investigation Buse, Full Blood Count, and Diagnostic Imaging.
5. Blood and Gross do match to replace a lot of blood in case of bleeding
6. Starve the patient "Nil By Mouth" 6 hours before surgery
7. Intake of vital signs to ensure stable patients
8. Wearing surgical gowns and oil cap
9. Send the patient to the operating theater (Dewan bedah)
.

Patient Care After Surgery (Post Operative Care)

1. Receive patients from the operating theater


2. Consuming vital sign every 15 minutes, then every ½ 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

Treatment medications given

1. Patients are given medications such as:

 Paracetamol TDS 1000mg for 5 days


. Action : acts as antipiratik and analgesics to patients.
Side effects : vomiting, nausea, abdominal pain.

 Tramal capsules 50 mg TDS for 5 days


Action : This narcotic type drugs act to reduce the pain experienced by
patients after surgery.
Side effects : constipation, nausea, dizziness, vomiting and weak pulse .

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Patients require adequate rest to the healing of wounds due to surgery

2. Patients should not make any heavy work to prevent incidents recurring hernia
3. Patients are encouraged to wear tight underwear
4. Patients are advised to reduce smoking because smoking can result in a patient
suffering from a cough that also can contribute to the occurrence of this hernia.
5. Patients should keep diet by eating foods that are nutritious and high in protein to
promote wound healing, such as fish
6. Patients are not allowed to apply water to prevent infection of surgical wounds in the
vicinity
7. Make sure that every doctor's appointment with a good compliance.
8. Patients should avoid emotional stress to speed up the healing process
9. Advise the patient to take care of personal hygiene.

10. Do refer to hospital if there are complications


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:

Daripada ‘clerking case’ yang saya lakukan di wad kenanga 3C Hospital Sultanah
Bahiyah ini, banyak pembelajaran dan pengalaman baru yang saya perolehi. Antaranya ialah
saya berdepan dengan situasi sebenar pesakit yang betul dalam keadaan yang sakit dan
bagaimana cara untuk menangani situasi tersebut. Disamping itu, pesakit juga banyak
memberi kerjasama semasa mendapatkan riwayat pesakit, pengambilan sejarah dan
pemeriksaan fizikal. Saya juga dapat mengetahui lebih lanjut mengenai penyakit ingunial
hernia dan penyebabnya. Saya juga boleh melihat sendiri simtom-simtom yang dihadapi oleh
pesakit yang sebelum ini hanya mengetahui daripada teori semata-mata. Saya juga
berpeluang mempelajari dan mengendali pengurusan pra dan post-operative ini dalam
keadaan sebenar. Selain itu juga saya dapat mempraktikkan penjagaan kejururawatan yang
dipelajari di dalam kelas. Akhir sekali saya dapat mengetahui dan mengenali ubat-ubatan
digunakan dalam merawat kes yang berkaitan dengan penyakit ini seperti kaedah tindakan
ubat, dos, cara pemberian, interaksi ubat dan kesan sampingan ubat tersebut.