KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

MOHD FADHLUR RAHMAN BIN NARAWI

Nama Pelatih : ………………………...………………………………………

No. Matrik : …………………………………………………….….……….

BPP2018-0673

2 2
Tahun : ……….........… Semester : ………………………..

HOSPITAL KOTA TINGGI

Kawasan Penempatan : ....………………………………………………..……………

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: Nombor K/P:

048127
-TIDAK PERLU DIISI -

Nama:

-TIDAK PERLU DIISI -

Jantina: Female Bangsa: Malay Pekerjaan: Umur: 27

Accountant

Alamat: No. Tel:

-TIDAK PERLU DIISI - -TIDAK PERLU

DIISI -

Hospital/Klinik: Hospital Kota Tinggi Tarikh: 12 Sept

2020

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama: Short Of Breath x 1/7 days

Sejarah Penyakit Kini:

 Coughing with yellow sputum
 No fever
 No vomitting
 No Diarrhoea
 No Tachypnoea

Sejarah Penyakit Lalu:

(Termasuk alahan ubatan)
 Patient never admitted to ward since she was diagnosed with bronchial
asthma since she was young
 She was on inhaler Salbutamol 2 puff tds/prn

Sejarah Keluarga:

 No history of diabetes mellitus

 No history of hypertension
 No other bronchial asthma found occur among her parents and siblings

Sejarah Sosial:

 Non-smoker
 Non-alcohol drinker

Sejarah O&G:

 Patient is single
 Menstrual cycle is normal
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1. Cardiovascular system
a) Normal
b) DRNM (dual rhythm no murmur)
c) S1S2 normal with regular rhythm
d) No chest pain while breathing

2. Respiratory system
a) Normal
b) Respiration rate - 20/min
c) No dyspnoea
d) Wheezing sound is heard during lung auscultation
e) Has ronchi

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

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

5. Excretory system
a) Bowel sound normal
b) Non-palpable kidney

6. Musculoskeletal system
a) Normal
b) Positive motor reflex
c) No muscle dystrophy
d) No tender or warm

7. Endocrine system
a) Normal
b) No thyroid gland enlargement
c) No tremor
BAHAGIAN 3: PEMERIKSAAN FIZIKAL

General Examination:

Bil Observation Results

01 Pain Score 3/10
02 Temperature 36.8℃
03 Respiratory Rate 20/min
04 Blood Pressure 120/74mmHg
05 Pulse Rate 94bpm
06 Pulse Rhythm Normal
07 Pulse Volume Good
08 Body Weight 60kg
09 Glaucoma Scale Score (GCS) 15/15
10 Oxygen Saturation (SpO2) 98% RA

Pemeriksaan Kepala dan Sistem Deria Khas:

(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)

 Head
 Inspection
i. No swelling or active bleeding
ii. No Discoloration noted
 Palpation
i. No Swelling

 Eyes
 Inspection
i. Up rolling eyeballs
ii. No Discharged found from both eyes
iii. No discoloration noted
 Palpation
i. No per-obital tenderness or swelling noted

 Ears
 Inspection
i. No active bleeding or swelling
ii. Both ears remain in same size
iii. No discharged found in both ears noted
iv. No abnormalities of hearing noted
 Palpation
i. No tenderness
ii. No mass palpated
 Nose
 Inspection
i. No bleeding or swelling
ii. In Normal shape of nose
iii. No discharge
iv. No nasal polyps seen
v. No nasal obstruction noted
 Palpation
i. No tenderness
ii. No mass found

 Throat
 Inspection
i. Cough and sore throat for 1/7 days
ii. Yellowish sputum occur
iii. No tonsil enlargement

 Mouth
 Inspection
i. Normal in shape
ii. Dry lips

 Neck
 Inspection
i. No abnormalities in shape
ii. No complaint of dysphagia
iii. No swelling
iv. Able to swallow
 Palpation
i. No tenderness
ii. No mass palpable
iii. No lymph node swelling
Bahagian Dada:
Jantung:

 Inspection
- No previous cardiac operation scars on the chest wall
- No abnormalities seen

 Palpation
- No chest wall pain or tenderness
- No presence of abnormal thrill
- Apex beat 5th intercoastal space midclavicular line

 Percussion
- Normal cardiac dullness on the 5th intercoastal space of the left
boarder

 Auscaltation
- Sound 1 and sound 2 heard clearly
- Dual rhythm no murmur (DRNM)
- Heart beat is normal

Paru-paru:

 Inspection
- Shape and symmetry of chest is normal
- Chest wall movement anteriorly and posteriorly normal and no
abnormalities
- Has coughing
- Breathelessness
- Tightness

 Palpation
- Chest expansion is symmetrical and normal
- Apex beat is normal
- No vocal (tactile) fremitus
- Ribs does not detect localisez pain

 Percussion
- Cardiac dullness
- Normal resonance at both lung

 Auscultation
- Breathe sound has ronchi, no crepitation
- Wheezing sound can be heard
- No added (adventious) sounds
- Air entry equal bilateral
Abdomen:
 Inspection
- No previous surgical scar seen
- No wound

 Palpation
- No pain during palpation on the abdomen
- No pain
- No tender

 Percussion
- No fluid thrill

 Auscaltation
- Bowel sound present and normal

Sistem Saraf:

 Positive tendon reflex

 Positive planta reflex
 Sensory functioning well
 Superficial touch normal

Anggota Atas dan Bawah:

 No deformity
 No clubbing of fingers
 No varicose vein
 Positive all movement (flexion, extension, abduction ect)
 Hand dominance: Right

Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
 No examination done
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

Cough and sore throat

with yellowish
sputum 1/7 days

Breath sound
auscultation : has
ronchi

BAHAGIAN 5: DIAGNOSIS

Diagnosis Sementara:
 Asthma

Diagnosis Perbezaan:
 Bronchopneumonia
 Bronchitis
 Chronic obstructive airway disease (COAD)

Diagnosis Tepat: Bronchial Asthma

BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN
RELEVAN

BIL INVESTIGATION RESULT

01 HB 13
02 TW 19.5
03 pH 266
04 Na 13.9
05 K 4.34
06 Ur 5.9
07 Cr 80
08 RbS 5.5
09 Ca 256
10 Mg 0.76

Blood investigation
1. Full Blood Count : to measure the Hb, platlet count, haematocrite and total white
differential count (infection)
2. Renal Profile : to measure the health state of kidney
BAHAGIAN 7: PENGURUSAN

Patient in the ward accompanied by her father at around 4pm from emergency
department Hospital Kota Tinggi.
1. Patient was admitted to be in ward Tanjung Perempuan
2. Patient was placed in the room as the patients condition was not severe.
3. Patient was rest in bed and taking patient history taking as main complaint.
4. Patient undergoing general examination and physical examination
(inspection, percussion, palpation and auscultation)
5. Vital signs such as body temperature, blood pressure, pulse rate and
respiratory rate were recorded.
6. Patient airways are open and patient is positioned in semi-prone.
7. Patient is given nebulizer A:V:N (1:2:3)
8. Patient vital sign monitored QID
9. Laboratory investigation were carried out
i. Blood Urea Serum Electrolyte (BUSE) - To measure kidney function
ii. Full blood count (FBC) - To detect infection
10. Radiology Investigation were carried out
i. Chest X-ray
ii. Computed Tomography (CT scan)
11. Let patient rest completely
12. Doctor plan
a) Continue nebulizer A:V:N (1:2:3) stat
b) IV Hydrocortisone Sodium 250mg STAT
c) Salbutamol 2 puff tds/prn
d) Tab prednisolone 30mg OD
e) Syrup Dephenhydramine HCI 15ml tds
f) Tab Bromhexine HCI 8mg tds
g) Tab Paracetamol 1gm tds/prn
h) TCA prn
i) Allowed discharge if patient condition is stable
BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

 Explain to patient and her family about the illness she was facing so that the family
can help the patient when she experiencing short of breath
 Explain to the patient and family about the important of taking a medication at the
right time and dosage
 Explain the side effect of the medication if not taken with the correct direction
 Also explain the important of the continues treatment
 Make sure patient has done the blood test and also TDM especially if patient
take medication such as sodium valproate
 Make sure patient use “medical aleert” so that it can be identified during seizures
attack
 Avoid high risk activity
 Avoid other development factor such as bright light
 Rush to any emergency department if shortness of breath or difficulty of breathing
occur to get emergency treatment
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:

During my clinical at Hospital Kota Tinggi, Ward Tanjung Perempuan perubatan. I

have learn a lot of medical cases and I have chosen bronchial asthma as my clerking
case. I have interviewed the patient and observe her treatment during her admission
at the ward. I now know the medication needed to treat bronchial asthma and how to
prevent a patient with asthma before they have an asthma attack. I learn the etiology
and pathophysiology of bronchial asthma and also the prevention of complication of
the case.
 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE CLERKING

Nama Pelatih: ………………………………………… No. Matrik: ………….……….

Tahun: …… Semester: ……… Kawasan Penempatan: ...…………………………

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: ………………………………………… No. Matrik: ………….…..…….

Tahun: …… Semester: ……… Kawasan Penempatan: ...…………………....……

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 : ……………………………………………