INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA

SULTAN AZLAN SHAH

ULU KINTA, PERAK

KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih MOHAMAD IKMAL HAKIMI BIN BUNYAIMI

No. Matrik : BPP2019-0027

Kawasan Penempatan : Klinik Otorinolaringologi

Hospital Teluk Intan
BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: Nombor K/P:

086745
-TIDAK PERLU DIISI -

Nama:

-Tidak perlu diisi-

Jantina: Bangsa: Pekerjaan: Umur:

LELAKI MELAYU SENDIRI 30 tahun

Alamat: No. Tel:

-TIDAK PERLU DIISI - -TIDAK PERLU

DIISI -

Hospital/Klinik: Tarikh:

Klinik ENT Hospital Teluk Intan 15/2/2022

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:

- Nasal congestion x 3-4/12 with allergic rhinitis symptoms

- Headache accompany nasal congestion x 3/12

Sejarah Penyakit Kini:

- Freq – daily/week affecting daily activity

- Occular symptoms – itching, redness
- No epistaxis
- No hyposmia/ anosmia
- No facial pain
- no fever
- no URTI
- no h/o trauma
 otherwise:

O/E:

- B/L facial nerve intact

- no facial tenderness

Sejarah Penyakit Lalu:

(Termasuk alahan ubatan)

- alleged MVA X 1 yeara ago

- sustain L/W over nasal bridge
- only seen in HKK ED (done T&S)
- never visit ENT
- (D) well from ED
- NKDA
- NKFA
- NKMI

Sejarah Keluarga:
- married
- has a daughter
- other family unknown for comorbid
- No allergic history

Sejarah Sosial:

- He is ex smoker (last smoking was 3 years ago)

- He is non alcoholic

KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1. Sistem kardiovaskular (CVS)

- Normal
- No tachycardia
- DRNM
2. Respiratory system
- Normal
- No tachypnic
- No dyspnea
- No wheezing/stridor

3. Circulatory system
- Normal
- No pale
- No cyanosis

4. Endocrine System
- Normal
- thyroid gland normal
- No lymph node enlargement

5. Exrectory system

- Normal

- Bowel sound normal

- kidney palpable
BAHAGIAN 3: PEMERIKSAAN FIZIKAL

Pemeriksaan Am:

a) Mental status : alert, concious

b) Orientation : people, place

c) Neuromotor : No seizures , No hemiperasis

Tanda Vital: (taken at 26/01/2022)

Penilaian kesakitan: 0/10

Suhu Badan: 36.3°C Kadar Pernafasan:18/min Tekanan Darah:113/88 mmHg

Kadar Nadi:83/min Ritma Nadi:Regular Isipadu Nadi:Normal

Berat Badan:84kg

Pemeriksaan Kepala dan Sistem Deria Khas:

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

Head: no wound, no scars, no bruise, no swelling

Eyes: no redness, no discharge

Nose: DNS, congested, no discharge, no epistaxis

Ears: no discharge, tympanic membrane clear, no swelling

Neck; thyroid gland normal, lymph node normal

Throat: normal tonsil, no extended jugular veins, no swelling

Bahagian Dada:

Jantung:

-inspection:

- Normal

- No scar

- No wound
- No barrel chest
- No deformiti

-palpation:

- No scar

- No bone fracture

-percussion:

- No scar

- No dullness sound

-Auscultation:
- DRNM

Paru-paru:

-inspection:
- normal
- normal expansion

- Symetrical while breathing

-palpation:
- palpable
- no tenderness
-percussion:

- Normal

- Resonance

-Auscultation:

- normal

- Air entry equal bilateral

Abdomen:

- soft
- no tenderness

-inspection:

- Normal

- No scar
- No any skin disease

-palpation:

- Normal

- No scar
- Bowel sound normal
-percussion:

- Normal

- resonance
- no dullness

-Auscultation:

- Normal

- Bowel sound heared

Sistem Saraf:

- Positive tendon reflex

- positive plantar reflex
- Sensory function
- Superficial touch normal
- Pain when prick
- gag reflex: Present

Neurology

Right Left
Tone N N
Power At least 5/5 At least 5/5
Reflex N N

Anggota Atas dan Bawah:

- No deformiti
- No clubbing fingers
- No varicose vein
- Positive all movement ( flexion , extension , abduction ,etc)
Lain-lain :

(termasuk genitalia , rektum dan sebagainya)

1)Genital

- Normal
- No tender
- No discharge

2) Rectum

- No per rectum mass

- No discharge
- No rectum prolapse
- No hemorrhoid

BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

- Congested
bilateral nasal

- Allergic Rhinitis
with Deviated
nasal septum
BAHAGIAN 5: DIAGNOSIS

Diagnosis
- Allergic Rhinitis with deviated nasal septum

Diagnosis Perbezaan:

- Sinusitis
- Nasal tumor
- Foreign body
- trauma

BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

RELEVAN

1. Nose Endoscopy (NES)

- to examine nose structural anatomy to find any abnormalities

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 there is an increase or decrease in haemoglobin

3. Nasopharyng swab for c&S

- to identify type of allergen that cause the allergic reactions

BAHAGIAN 7: PENGURUSAN

Management in ORL Clinic

1. Daftar pesakit pada kaunter saringan covid-19

2. Ambil tand vital pesakit: BP, pulse rate, temp, spo2, pain score

3. Lakukan penyiasatan:
a) Ujian Nose endoscopy
b) Ujian darah FBC
c) Nasopharyng swab for c&S

4. Medication:
a) Avamys nasal spray 2p OD x 2/12
b) Tab loratadine 10mg OD X 2/12

5. Surgery
a) Septoplasty to straighten bone and cartilage of nasal septum

6. Beri TCA 2/12 untuk melihat perkembangan dan komplikasi jika ada

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

- Make sure patient take all medicine accordingly

- Patients should drink adequate amount of wáter to prevent hydration
- Patient should eat balance diet to supply enough nutrien to the body
- Make sure that every doctor’s appoinment with a good compliance
- Advise the patient to take care of personal hygiene

- Advised patient to not smoking and drinking alcohol

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 Klinik ENT, saya berpeluang mendapatkan pengalaman

dan pengetahuan yang lebih mendalam merangkumi pelbagai aspek. Kerjasama yang baik dari staf

kakitangan klinik sangat banyak membantu saya memahami sekaligus menyiapakan case clerking ini

dengan baik.