DIPLOMA IN MEDICAL AND HEALTH SCIENCE

CASE CLERKING

Name of Student : WAN AMEERAMIRULZAMAN BIN AHMAD

Matric No : BPP2020-0282

Semester : SEMESTER 3

Placement : KLINIK KESIHATAN PETRA JAYA

PART 1: PATIENT’S PARTICULARS

Registration Number : IC Number :

13-3930 -TIDAK PERLU DIISI-

Name :

-TIDAK PERLU DIISI-

Sex : Male / Female* Race : Occupation : Age :

MALE CINA PESARA 60

Hospital / Clinic Date :

10 / 10 / 2021
KLINIK KESIHATAN PETRA JAYA KUCHING (KKPJ)

* Indicate the gender

PART 2 PATIENT’S HISTORY

CHIEF COMPLAINTS :

➢ Pain over right fore arm since 11 am today

HISTORY OF PRESENT ILLNESS :

60/male/CINA
UL - NKMI
C/O - Allerged Fall of bathroom today ( 8/10/2021) at 11 am.
- pt. fall and landed swollen at right fore arm / Rom limited due to pain.
- no open wound / no active bleeding.
- no ioc / no ent bleeding / no vomiting / no nauseated.
- no SOB / no chest pain / no palpitation
- GCS - 15 CE-4 / V-5 / M-6)
- past trauma , deformity at Right fore arm and pain.
- pain score 5/10

PAST MEDICAL HISTORY :

(Including History of Allergies)
- no known medical illness
- no allergic to any medication
- no allergic to any food

FAMILY HISTORY :
- Father : no history of medical illness
- Mother : diabetes melitus

SOCIAL HISTORY :
- Not smoker
- no history of taking drug
- married
- retiree

O & G HISTORY

REVIEW SYSTEM :

1. Cardiovascular system
- Apex beat at 5th intercostal space , mid dalvicular line.
- DRNM
- normal cardiac dullness

2. Respiratory system
- no Rhonchi / no crepitus sound
- lung expasion equal biluteral
- lung clear / a/e equal

3. Alimentary system
- soft / no tenderness
- no dullness
- bowel sound present
- liver palpable
- no acites found

4. Endorine system
- no scars
- no thyriod enlargement

5. Musculoskeletal
- united range of movement. - no pulseless
- no laceration wound - no paralysis
- slighly detarmity - no pallor
- no parathesra

6. Nerve system
- normal tendon reflex, bicep reflex and tricep reflex tt

7. System genito urinary

- no hematuria
- no dysuria
- no abnormal dischage
SPECIFIC HISTORY FOR PAEDIATRICS:

Birth History:

Feeding History:

Developmental History:

IMMUNIZATIONS:

Types of Date Types of Immunization Date

Immunization

BCG DPT + Polio Dose 1

Hepatitis B Dose 1 DPT + Polio Dose 2

Hepatitis B Dose 2 DPT + Polio Dose 3

Hepatitis B Dose 3 DPT + Polio Booster 1

Measles DT + Polio Booster 2

(Other Immunizations)
PART 3: PHYSICAL EXAMINATION

General Examination: alert / walk in / speak in fall sentence / GCS - 15 CE - 4

/ V-5 / M-6) hydration

Vital Signs:

Pain Score: 5/10

Body Temperature:36.3℃ Respiration:19/min BloodPressure:120/85mmHg

Pulse:89 bpm Rhythm:regular Volume:strong

Body Weight:64.5kg Urine (Glucose):6.5mmol/L Urine (Albumin):

Examination of Head and Special Senses:

(including Mouth, Throat, Ears, Nose, Eyes and Neck):

Head:
No wound overhead
-no scar
-no hematoma

Face:
-no over facial area
-no sinosis

Hear:
-no ear bleeding / dischange bilateral.
-no ringing sound

Eye:
-clear conjunetiva / pupil reactive to light
-no bleeding
-no would laeetron or abrason at eye or cornea
-no raccon eyes.

Neck:
-thyriod not palpable
-jagular veins palpable
-no tracheal
Throat:
-no tonsil enlargement
-no redness on phanrynx
-no exudate seen

System respiratory
Inspeksi : - no scars
-no open wound
-no prgeon chest
-normal chest movement, equal chest rise
-no hematoma
-no swelling
Palpasi : -symetrical chest expansion
-no tenderness
-no emphysema
Perkusi : -no dullness
-normal resonance sound both lungs
Auskultasi : -arv entry equal brlateral
-no rhonchi, creprtry and transmited sound

System cardiovascular
Inspeksi : -no scars
-no deformity
Palpasi : -apex beat palpable
-normal apex beat 89 bpm
Perkusi ; -normal cardiac dullness
Auskultasi : -no murmur
-s1 s2 present
-dual rhytm
-no muffled heart sound

System alimentary
Inspeksi : -no scar
-no hematoma
-no wound
-no abdominal distended
Auskultasi : -normal bowel sound
Palpasi : -soft, no tender
-liver is palple
-no guarding sign
-spleen and kidney not palpable
Perkusi : -no fluid thrill
Sistem saraf :

Reflek Kanan Kiri

Pupil Reactive Reactive
Bisep tt tt
Trisep tt tt
Brachoradialis tt tt
Lutut tt tt
Ankle tt tt
Plantar ↓↓ ↓↓

Sistem musculoskeletal :

Anggota atas :
Inspeksi : - no open wound
- Deformity since right for arm
- limited rom at right fore arm
- no hematoma and redness

Palpasi : - deformity felt at right for arm

- radial and branchial pulse present
- good pulse volume
Sirkulasi : -sensation present
-no numbness
- warm

Anggota atas Jenis pergerakan Kekuatan

Kiri Kanan
Sendi bahu Abduksi 5/5 5/5
Adduksi 5/5 5/5
Rotasi 5/5 5/5
Sendi siku Fleksi 5/5 5/5
Ekstensi 5/5 5/5
Pergelanggan tangan Fleksi 5/5 4/5
Ekstensi 5/5 4/5
Rotasi 5/5 4/5
Jejari Fleksi 5/5 5/5
Ekstensi 5/5 5/5
Anggota bawah:

Inspeksi : -no determity seen

-no wound
-no hematoma
Palpasi : -no deformity
-strong pulse volume
Sirkulasi : -skin warm
-Pulse volume strong

Anggota bawah Jenis pergerakan Kekuatan

badan Kiri Kanan
Sendi pinggul Fleksi 5/5 5/5
Ekstensi 5/5 5/5
Rotasi 5/5 5/5
Sendi lutut Fleksi 5/5 5/5
Ekstensi 5/5 5/5
Pergelangan kaki Dorsifleksi 5/5 5/5
Rotasi 5/5 5/5

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

1. Pemeriksaan genital :
-no swelling
-no bleeding or discharge
-no wound
-no tenderness
-no abnormal detected

2. Pemeriksaan rectum
-no sign of atanal fisure or erfistula anal
-no prostate enlargement
-no heamorriod seen
PART 4: SUMMARY OF IMPORTANT AND RELEVANT FINDINGS

NOD
-No swollen
-no scrolum
edema

- No
prostate
- no
hemorroid
seen
- no
melena
fresh blood
seen

No pedal edema

PART 5: DIAGNOSIS

Provisional Diagnosis:
-closed fracture right distal radius

Differential Diagnosis:
-radius distocation
-closed fracture right distal ulna
-scaphord fracfure
-radiocarpal irgament injury
PART 6: INVESTIGATIONS (Laboratory, Radiological and other
relevantinvestigations)

1. Full blood count

Tujuan : to find any infection in blood

Kompenen darah Keputusan Unit Julat normal

Heamaglobin
Rbc
Twc
Platelet

Interpretasi : not related to this case

2. Blood urea serum Electrolyte (BUSE)

Tujuan : to find abnormalities in kidney

Test Result Unit Ref ranges

sodium
potassium
Chloride
Urea
Calcium
Creatinine

Interprestasi : not related to this case

3. Chest x-ray

Tujuan : to find any abnormalities in chest

Keputusan : no fracture on claricle or dislocation or fracture

Interprestasi : no fracture

4. ECG

Tujuan : to find abnormalities electrical actities in heart

Keputusan : to find any abnormalities at right radrus

Keputusan : fracture right distral radius

5. Ujian spesifik

Jenis : right radrus ulna (AP lateral)

Tujuan : to find any abnormalities at right radrus

Keputusan : fracture right distal radius

6. Lain-lain ujian :

Jenis : right hand (AP lateral)

Tujuan : to find abnormalities at right hand

Keputusan : right distal radius fracture

PART 7: MANAGEMENT

1. Klinik kesihatan
- calm pt to give reasurance
-take vital sign (BP, temp, spo2, PR, Hpc, GCS)
-take history from patient and relatives for mechanism of injuries (place / time)

a) Primary survey

1. Airways - secure airways

- clear and open airways if needed
- apply cervical collar if needed

2. Breathing - inspection-nod (abnormal movement of chest during breathing)

- palpation - symmetrical chest expansion
- percussion - normal resonance, no hyperresonance , no
dullness.

3. Circulation - vital sign - pr, bp, temp, spo2

- secure iv line for giving medication or resusitation

4. Disability - GCS 15/15 CE - 4/ V-5 / M-6)

- patient allert / talk in full sentences and responsive
- pupil reactive

5. Exposure - clothes remove to seek any abnormalities over body.

- no active bleedings
- abrasion wound at R fore hand.
- swelling and pain at R fore hand

b) Secondary survey

Symptom : sustained pain R fore arm , pain score 4/10

No open wound

Allegies : no known drug or food allergeis

Medication : patient doesn’t has take any medication

Past history : no history of medical illness

Last and intake : patient darmed eating “mee goreng” at home around 10.00
am

Event prociding : patient darmed having pain at R fore arm after accident
6. Head to toe examination ( DCAP - BILS)

Determities : seen at R fore arm

Confusion : no hematoma

Abrasion : no abrasion wound

Puncture : no puncture wound

Burn : no burn

Laceration : no laceration

Swelling : swelling at R fore arm

7. Medication
-1m diclofenac 50mg stat to reduce pain
-1m ATT 0.5 ml stat

8. Imaging investigation
-R fore arm x-ray AP / lateral at klinik kesihatan petra jaya
- patient refer to klinik kesihatan petra jaya for x ray and futher management
with their own transport.

9. Apply arm sling to patient to secure his hand

10. Patient refered to klinik kesihatan petra jaya for x-xray and futher
managemant with their own transport.
2. Jabatan kecemasan dan trauma

a) Calm the patient to give reasurance

b) Patient triage to yellow zone for futher management
c) Vital sign :
-bp : 125/80 mmHg
-pr : 90 bpm
-SPO2 : 98 %
- temp : 36℃

d) History taken from patient or relative for mechanism of injuries

e) Secondary Assement

Symtom : sustained pain at R fore arm, pain score 5/10, no open wound.

Allergies : no known drug or food allergies

Medication : patient does take any medication

Past medical history : patient does have history of medical illness

Last oral intake : patient eating mee goreng at home 10.00 am.

Event prosiding : patient darmed pain at R fore arm after accident.

Imaging investigation
- patient sent to x-ray R fore arm AP and obligue
Bahagian 8 : nasihat relevan kepada pesakit / penjaga

1. Take medication as instructed to monitor by Mo.

2. Come for follow up as instructed to monitor progress
3. Come stat if any complication occur
4. Keep the pop clean and drug
5. Take good diet
6. Increase fluid intake to prevent dehydration

Bahagian 9 : laporan reflektif :

( Berikan komen mengenai pembelajaram dan implikasi pengurusan kes ini

yang telah diperoleh daripada pengkajian kes ini )

Pengurusan : Baik

Memuaskan

Lemah

Refleksi pembelajaran yang diperolehi daripada pengajian kes ini :

I have learned how to manage orthopedic casses especially in radial ulna fracture . I
also learned many things how to manage ortopedic cases such as CMR,how to apply
back slap and how to apply pop. This case clarking make me improve my knowledge
about orthopedic and its was remind about primary and secondary survey at clinic
Kesihatan Petrajaya. I’am so thanksfully to all staff and my team for willing to share
their knowledge to me.