KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih : F

No. Matrik :B

Tahun : TIGA Semester : DUA

Kawasan Penempatan :J

BAHAGIAN 1 : BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran : Nombor K/P :

A
-TIDAK PERLU DIISI-

Nama:

-TIDAK PERLU DIISI-

Jantina : Bangsa : Pekerjaan : Umur :

Lelaki / Perempuan MELAYU TIDAK 16 TAHUN
BEKERJA

Alamat : No. Tel :

-TIDAK PERLU DIISI- -TIDAK PERLU DIISI-

Hospital / Jabatan / Klinik : J Tarikh : 2022

BAHAGIAN 2 : RIWAYAT PESAKIT

Aduan Utama :
-having abdominal pain
-no vomitting
-no dizziness
-no sob
-denied Covid contact

Sejarah penyakit kini :

-pt come to ED on and complain having abdominal pain
-after been observed at the green zone, she complain having pain at right iliac fossa .
-pt complain feel pain when been palpate

Sejarah penyakit lalu (Termasuk alahan ubatan) :

-no history of illness

Sejarah keluarga :
HPT

pt

Sejarah sosial :

-no smoking
-no alcohol

Sejarah Obstetrik & Ginekologi :

-no history of illness

KAJIAN SEMULA SISTEM TUBUH BADAN:

CVS :
-pt feel palpitation because of the abdominal pain
-pt sweeting

CNS :
- no abnormalities
- no seizure

GIT :
-no food poisoining, no bleeding
-no vomitting

Respiratory System :
-pt able to breath normally
-no sob

Endocrine System :
-no abnormalities

Urinary System :
-no abnormalities

Muskuloskeletal System :
-pt able to walk but having abdominal pain
-no fracture

Genital System :
-no abnormalities
 BAHAGIAN 3 : PEMERIKSAAN FIZIKAL

Pemeriksaan Am:

Tanda Vital:-

Penilaian
kesakitan:6/10
Suhu badan:36.8 Kadar pernafaan: 20/min Tekanan
darah:
Kadar nadi:67/min Ritma nadi: regular Isipadu
nadi:normal
Berat badan:38kg

Pemeriksaan kepala dan sistem deria khas: (mulut, tekak, telinga, hidung, mata dan leher)

Telinga:
– no hearing loss

Mulut
-Able to speak,no fracture or bleeding

Tekak
-no pain, able to swallow

Mata
-no abrassion,no pain

Leher
-no injury, no fracture or spinal fracture,no cervical collar

Hidung
-able to smell, no bleeding
 Bahagian Dada:
Jantung:

Inspection :
-no scar no bleeding

Palpation :
-no pounding,no
fluttering, and regular

Auscultation :
-dual rhytm no murmur

Paru-paru:

Inspection :
-no rib fracture, no bleeding,no flait chest
Palpation :
-symmetrical movement of lung
Percussion :
-resonance
Auscultation :
-no ronchi, no crepitus

Abdomen:

Inspection :
-no dilated vein,no scar

Palpation :
-pt’s abdomen feel tender
-patient positive towards rebound tenderness test after been palpate at right iliac fossa
-rovsing sign been seen towards patient after been palpate at lower left quadrian

Percussion :
-resonance in all quadrants
-no fluit trill

Auscultation :
-bowel sound present

Sistem Saraf:

GCS e4 v5 m6

EYE
4.Spontaeous (X)
3.To speech
2.To pain
1.No respond

VERBAL
5.Oriented (X)
4.Confused
3.Inaprropriate word
2.In comprehensiveable word
1.No respond

MOTOR
6.Obey command (X)
5.Move to localise pain
4.Flexion withdrawal pain
3.Abnormal flexion
2.Abnormal extension
1.No respond

GCS patient : 15/15

Anggota Tangan dan Kaki:

Lain-lain: (termasuk Genitalia, Rektum, dan sebagainya)

-no abnormalities
-rectum no abnormalities
 BAHAGIAN 4 : RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

Right Iliac Fossa

pain after been
palpate,positive
rebound tenderness

BAHAGIAN 5 : DIAGNOSIS

Diagnosis Sementara: Acute Appendicitis

Diagnosis Perbezaan: 1. Acute Cholecystitis

2. Perforated peptic ulser
3. Renal colic
4. Acute pancretitis
 BAHAGIAN 6 : PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN RELEVAN

1.Blood C & S
- to investigate the present of infection in blood to give antibiotic treatment

2.Ultrasound
-to scan the abdomen in order to get clear image of swallon appendix to diagnose the
patient

3.Rebound Tenderness
-a pre-investigation in diagnosing acute appendicitis,pt abdomen been palpated at right
iliac fossa.

4. Rovsing Sign
- palpation at lower left quadrian that give pain at lower right quadrian if pt was acute
appendicitis

5.MRI
-will give more efficient and more clear image in diagnosing patient

6.Ct Scan
-create cross-sectional images on soft tissues of the abdomen to help in diagnose patient
BAHAGIAN 7 : PENERANGAN PENGURUSAN RAWATAN

Plan at ED department :

1.Refer gynae TRO gynae pathology

2.Admit ward 4B, been arrange for PCR
3.Book for open appendicectomy in ward
4.KNBM with IV drip 4 pints ( 2 pints Normal Saline + 2 pint Dextose 5%)-
in 24 hours.
5.Medication :

-IV cefobid 1g BD
Treating bacterial infection in the different parts of the body.

-IV flagyl 500mg TDS

To treat infection that happen because of the appendicitis

-IV tramal 50mg TDS

As a pain relief or anti inflammating towards patient because complaining
having abominal pain
 BAHAGIAN 8 : NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Get enought rest to ensure the pain to fast relieve.

2. Do not doing activities such as sport,lifting heavy things that may make
the abdomen feel more pain.
3. Take painkiller when needed .
4. Fasting at ward as the pre-operation preparation before go to operation
theater.
5. Never skip medication been arranged by doctor ,take medication
according to the scedule.
6. Take a lot of water to ensure the good circulation of blood
LAPORAN REFLEKTIF:

(Berikan komen mengenai pembelajaran & implikasi pengurusan kes ini yang telah diperolehi
daripada pengkajian kes ini)

Pengurusan kes: Memuaskan Lemah

Baik

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini:

From the study that i have made, i can observe and learn about the
management towards the patient which have been diagnosed as acute
appendicitis.Now i know the step been taken to treat those type of
patient.Before giving treatment,many investigation been done to ensure
and comforming the diagnosis towards patient is relevent.If the result is
telly and relevent,the treatment been given also will give the best result
towards patient.