DIPLOMA IN MEDICAL AND HEALTH SCIENCE

CASE CLERKING

Name of Student : WAN AMEERAMIRULZAMAN BIN AHMAD

Matric No. : BPP 2020-0282

Semester : SEMESTER 3

Placement : KLINIK KESIHATAN PETRAJAYA

PART 1: PATIENT’S PARTICULARS

Registration Number: 7 IC Number:

-LEAVE BLANK -
Name:

-LEAVE BLANK -
Sex: Male Race: Malay Occupation:- Age: 4 Month

Address: Tel No.:

-LEAVE BLANK - -LEAVE BLANK -

Clinic: KKPJ Date: 8.10.2021

PART 2: PATIENT’S HISTORY

Chief Complaint:
• Yellowish discoloration of the skin
• Cough and fever on and off
• Satisfactory on child, still active
• Not getting enough breastmilk
History of Present Illness:
• Not feeding well
• Feet yellow

Past Medical History:

• NIL

Family History:
• Asthma (late father)
Social History:
• Single mother.
• Smoking (late father)

REVIEW OF SYSTEMS:

Endocrine system :
• No abnormalities in the thyroid gland
• No moon face
• No abdominal distension
Cardiovascular system :
• No murmurs
• Normal heart beat
Respiration system :
• No short of breatness (SOB)
• No wheezing
• Cough
• Fever on and off
Alimentary system :
• Normal
 • Can breastfeed as usual
Musculoskeletal system :
• Hand and foot movements as usual
Nerves system :

• No abnormalities on posture

• Dilation of pupil is normal

• Positve tendon reflex

• Positive plantar reflex

• Positive bicep and tricep reflex

• Normal senses
Genital urinary system :
• No hematuria, normal urine colour.
• No malena stool
• Stool are pale yellow

SPECIFIC HISTORY FOR PAEDIATRICS

Birth History:
• Normal delivery on 2nd June 2021
Feeding History:
• Baby usually breastfeeding 7 time a day, but currently baby had poor appetite and
only breastfeed for 5 times.
Developmental History:
• Weight body loss
• Height development normal
• Head development normal
• Chest development normal
IMUNIZATION

Types of Date Types of Immunization Date

Immunization

BCG 02.06.2021 DPT + Polio Dose 1 02.08.2021

Hepatitis B 02.06.2021 DPT + Polio Dose 2 02.09.2021

Dose 1

Hepatitis B 02.07.2021 DPT + Polio Dose 3 -

Dose 2

Hepatitis B - DPT + Polio Booster 1 -

Dose 3

Measles - DPT + Polio Booster 2 -

PART 3: PHYSICAL EXAMINATION

General Examination:
• Mental status examination : Conscious
• Emotional status : Baby cry
• Activity level : Weak Respiration : Normal
• Skin intergrity : Dehydration some yellowish skin colour
• Vission : Yellowish present some yellowish colour
• Nutritional status : Poor appetite
• Sleep pattern : Normal
• Speech : Good
• Bladder pattern : Low urine output
• Bowel Pattern : Pale yellowProthesis : NIL
Vital Sign:
• Pain Score: 0
• Body Temperature : 38.6℃
• Respiration : 107 breath per minutes.
• Blood Pressure: 58/35 mmHg
• Pulse : 115 bpm
• Body weight : 5.6 kg
• Height : 51cm
 • BMI : 21.53 kg/m2
• Serum bilirubin (SB) : 5mg/dl

EXAMINATION OF HEAD AND SPECIAL SENSES

Skin
• Yellowish skin due to deposition of bilirubin
• Petechiae
Eyes
• Yellowing of eyes periphery of the conjunctiva
Abdomen
• Hepatomegaly may be present
Neorological
• A flapping tremor may be present
• Changes in muscle tone
• Seizures
• Microcephaly

CHEST

Heart:
• Normal heart size and shape
• No abnormalities
Lungs:
• Normal lung size when expand
• Normal lung volume
• No abnormalities
Abdomen:
• No scar
• Yellowish of skin
• Hepatomegaly
• Dry umbilical cord
Nervous System:
• No abnormalities on posture
• Dilation of pupil is normal
• Positve tendon reflex
 • Positive plantar reflex
• Positive bicep and tricep reflex
• Normal senses
Upper Extremities:
• Abnormalities absent
• No swelling
• Normal flexsion, extension, abduction, adduction and rotation
Lower Extremities:
• Abnormalities absent
• No swelling
• Normal flexsion, extension, abduction, adduction and rotation
• Others:
• (Including Genitalia, Rectum and other relevant examinations)
• Dark urine
• Pale yellow stool

PART 4: SUMMARY OF IMPORTANT AND RELEVANT FINDINGS

PART 5: DIAGNOSIS
Provisional Diagnosis:
• Neonatal jaundice
Differential Diagnosis:
• Neonatal hepatic
• Viral infections
• Metabolic defects

PART 6: INVESTIGATION ( LABORATORY, RADIOLOGICAL, AND OTHER

RELEVAN INVESTIGATIONS )

• FBC help to diagnose a wide range of illnesses, infections and diseases.

• Reticulocyte count to help figure out the types of illnesses that affect the blood,
such as hemolytic anemia.
• Serum bilirubin test to determine the level of bilirubin is normal or abnormal in a
newborn’s blood serum.

PART 7: MANAGEMENT

• Determine birth weight, gestation and postnatal age

• Assess clinical condition, degree of jaundice
• Decide whether jaundice is physiological or pathological
• Look for evidence of kernicterus in deeply jaundiced
• Measures bilirubin by jaundice meter
• Lab test : LFT, reticulocyte count, hbA1c, wbc, rbc, RFT
• Phototherapy intravenous immune globulin (IVIG)
• Exchange transfusion
• Exchange nutrition, to prevent weight loss, recommend more-frequent feeding or
supplementation to ensure that baby receives adequate nutrition

PART 8: HEALTH EDUCATION AND ADVICE TO PATIENT / GUARDIAN

• Enough breastfeeding
• Good environment
• Aware of baby’s development
• Avoids baby from pet example cat and dog
 • Avoids baby from smoker
• Follow up baby’s for medical check up
• Advice mother to take baby immunization

REFLECTIVE REPORT

Based on my experience in MCH department for 2 days in KKPJ, I learned about mother
and child health care. As I take the neonatal jaundice for my case study, I studied the
symptoms of the disease, take the vital sign, physical examination and management of
jaundice care. Beside, I also learned about the development of the baby including the
immunization of child.
In this case, jaundice is high risk for the baby to get low blood volume such as
anemia. Jaundice without treatment can cause death. Other then that, lab test is
important such as serum bilirubin test to determined weither the level of bilirubin in the
blood is normal nor not. Futheremore, I had improve my skill to use related equipment
and apllied to the patients. Lastly, I hope I can handle this case better in the future as I
becoming a Assistant Medical Officer.