KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih : MUHAMMAD FARDZLI BIN MATJAKIR

No. Matrik : BPP2018_0677

Tahun :2 Semester :2

Kawasan Penempatan : WAD PEMBEDAHAN

HOSPITAL TEMENGGONG SERI MAHARAJA TUN
IBRAHIM

____________________________

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: Nombor K/P:

0411102-20 -TIDAK PERLU DIISI -

Nama:

-TIDAK PERLU DIISI -

Jantina: Lelaki/ Bangsa: Pekerjaan: Umur:

Perempuan* -
37 TAHUN
LELAKI Malay
Alamat: No. Tel:

-TIDAK PERLU DIISI - -TIDAK PERLU

DIISI -

Hospital/Klinik: Tarikh:

HOSPITAL TEMENGGONG SERI MAHARAJA TUN IBRAHIM 1/9/2020

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:
- Abdominal pain for 1 week

Sejarah Penyakit Kini:

a) Patient was apparently all right 1 week ago when he developed

abdominal pain
- Generalised
- Intermittent, colicky
- No radiation of pain
b) Also associated with vomiting for the past 1 week
- He claims that he vomits whatever he eats
- Vomits food particles and fluids
- No bile content
c) Loss of appetite ( LOA ) for 1 week
d) Abdominal distension for 1 week
e) Not reducing
f) Unable to BO for the past 4 days
- Patient claims that he initially had diarrhea for the past 3 days
- Then following that he had no more BO
- But he still does pass flatus

Sejarah Penyakit Lalu:

(Termasuk alahan ubatan)
- Allergic to seafood
- Not taken any traditional drugs or treatment
- The patient has never had a respiratory problem
- The patient has not had a contagious disease (penyakit berjangkit)

Sejarah Keluarga:
- Married
- First son out of TWELVE ( 12 ) siblings
- No history of malignancies among family members

Sejarah Sosial:
-Smoker
-not IVDU
-Sleep 8 hours daily
-non alcoholic
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1. Cardiovaskular system
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 – 20/min
c) Pulse rate – 69/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

5. Exrectory system
a) No hematuria
b) Bowel sound sluggish
c) No abdomen pain
d) Kidney palpable

6. Musculoskeletal system
a) Normal
b) Muscle reflex positive
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

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 1/09/2020 @ 9.30 am)

Penilaian kesakitan : 2/10

Suhu Badan : 37°C
Kadar Pernafasan : 20
Tekanan Darah :140/74 mmHg
Kadar Nadi : 69/min
Ritma Nadi : Regular
Isipadu Nadi : normal

Berat Badan: 66KG Ujian Urin Glukosa: 8.3 Albumin:-VE

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 eyes
-no uprolling 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:

Normal

1) Inspection
a) Normal
b) No scar
c) No any skin disease

2) Palpation
A) Tense, generalised tenderness
B) Positive guarding
C) Positive rigidity
 3) Auscultation
a) Bowel sound sluggish

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) Normal scrotum, no swelling
b) tender

2) Rectum
a) normal
b) No discharge
c) No rectum prolapse
d) No hemorhoid
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

BAHAGIAN 5: DIAGNOSIS

Diagnosis Sementara: Intestinal Obstruction

Diagnosis Perbezaan: Acute Cholecystitis, Acute Apendicitis, Perforated Peptic

Ulcer, Acute Pancreatitis

BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

RELEVAN

1) 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) :16.80×10^3 µL (5.2 - 12.4)
b) RBC (Red blood cell) : 2.63×10^6 µL (4.50 - 5.50)
C) Hgb(Haemoglobin) :14.5 g/dL (13.0 - 17.0)
D) Hct(Hematocrit) :19.4L/L(0.39 to 0.51)
e) Platelet :339 x 10^3/uL (150-410)

2) 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)

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

Result:
- Dilated small bowel
 4) 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

1. Patient was admitted

2. Patient was placed in the room as the patient’s condition which is not
severe .
3. Patient was rest in bed and taking patient history as the main
complaint, history.
4. Patients 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 was admitted to be nil by mouth (NBM) and inserted intravena
infusion with FOUR ( 4 ) pints, 2 Normal Saline, 2 Dextrose Saline.
7. Patient was kept in Ryles tube to be free flow and follow by FOUR
( 4 ) hourly aspirate.
8. Patient was observed for checking abdominal distension.
9. Laboratory investigations were carried out as Full Blood Count
( FBC ), Renal Profile ( RP ).

Preparation and Care of Patients Before Surgery (Pre Operative Care)

1. Describes the surgical procedure " laparotomy "

advantages and complications derived from patient.
2. Advising the patient not to worry to face surgery
3. Obtain consent from the patient or person responsible
4. Confirm written consent for the procedure from the patient or person responsible
5. Doing investigation Buse, Full Blood Count, and Diagnostic Imaging.
6. Prepare blood and Group Cross Match to replace a lot of blood in case of bleeding
7. Starve the patient as "Nil By Mouth" 6 hours before surgery
8. Intake of vital signs to ensure patient is in stable condition
9. Patient wears surgical gowns and oil cap
10. Send the patient to the operating theatre room (Dewan bedah)
Patient care after surgery (post operative care)

1. Receive patient from the operating theatre room

2. Consuming vital sign every ONE ( 1 ) hour to monitor development as the
first post- operative patient
3. Keep Nil By Mouth with Intravena Drip.
4. Do normal dressing three times a day ( TDS ) over the laparatomy wound
5. Patient is continued with antibiotics and trace tissue Culture & Sensitivity.
6. Patient is fully rest on the bed.

Treatment medications given

1. Patient was given medications

such as: IV Fentanyl 90mcg stat

and OD
Action : acts as anesthesia and analgesic to patient.
Side effects : abdoment pain, agitation, constipation, headache,
dry mouth, vomiting

IV Morphine 4mg
Action : acts as analgesics
Side efftects : constipation, itchy skin, headache, dizziness

Nursing care
a) monitoring vital signs of blood pressure, pulse and respiration
and body temperature.
b) strictly observing and recording Input Output chart
c) observe and detect any bleeding
d) maintain patient in good comfortable and safety condition
e) maintenance of intravena infusion
f) patient hygiene as nails, hair, bowel and bladder
provide appropriate nutritional diet, High protein diet
BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. patient requires adequate rest to the healing of wounds due to surgery

2. Patient should keep diet by eating foods that are nutritious and high in protein to
promote wound healing, such as fish
3. Patient is not allowed to apply water to prevent infection of surgical wounds in the
vicinity
4. Make sure that every doctor's appointment with a good compliance.
5. Patient should avoid emotional stress to speed up the healing process
6. Advise the patient to do personal hygiene.
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:

Dengan melakukan kes ini,saya telah banyak mengetahui tentang

penyakit/pembedahan ini (intestinal obstruction). 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 dapat gunakan ilmu ini dimasa akan datang
semasa saya praktikal di tempat lain atau pun semasa saya bekerja nanti.Jika
penyakit ini ada lagi, saya percaya boleh mengendalikan kes ini dengan sebaik
mugkin .Selain itu,saya telah dapat pengalaman yang berharga dalam hidup saya
kerana boleh mengikuti perkembangan pesakit ini. 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.
 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE CLERKING

Nama Pelatih: …MUHD FARDZLI BIN MATJAKIR… No. Matrik: BPP2018-0677

Tahun: 2 Semester: 2 Kawasan Penempatan: WAD Pembedahan HTSMTI
Kulai
Bil. Perkara Wajara Skor Catatan
n
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: …MUHD FARDZLI BIN MATJAKIR… No. Matrik: BPP2018-0677

Tahun: 2 Semester: 2 Kawasan Penempatan: WAD Pembedahan HTSMTI
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 : ……………………………………………