CASE CLERKING

PRESENTATION
NAMA : ANELKA LOUIS
NO. CLASS : BPP2020-0189
SEMESTER : TIIS1
PLACEMENT : KLINIK KESIHATAN PENAMPANG
PATIENT’S INFORMATION

• Registration number : 12-3905

• Sex : Male
• Race : Kadazan
• Occupation : Farmer
• Age : 41
• Clinic : Klinik Kesihatan Penampang
• Date : 18th October 2021
PATIENT’S HISTORY

• Chief complaint
• Stomach pain x 2/7
• History of present illness
• Pain at right lower quadrant
• Graded as 4/10 in pain severity
• Otherwise
• No headache
• No fever
CONT…

• Past medical history

• Allergic with seafood (crab)
• Diagnosed with hypertension (2016)
• No medical illness
• Family history
• Father : underlying diabetes on
medication and follow up treatment
• Mother : NIL
• Married and living with wife
• 1st child of 3 siblings
CONT…

• Social history
• Occasionally Alcoholic
• Smoker
• 4 /12 cigarettes /day
• Associated brands
REVIEW OF SYSTEMS

• Cardiovascular system • Endocrine system

• No clubbing fingers • No tremor
• No murmur • No thyroid enlargement
• Respiratory system • No polyuria
• Airway clear • Musculoskeletal system
• No cough • Muscle tone in good condition
• No URTI • No muscle pain
• No dyspnea • No joint pain
• Circulatory system • Gastrointestinal system
• No pale • No nausea
• Capillary refill time less than 2 • Sharp pain in lower gastrointestinal
sec(<2sec) abdomen
PHYSICAL EXAMINATION

• General Examination • Body temperature

• Capillary refill time <2 seconds • 36.5*c
• Conscious • Respiration
• Pulse volume in good condition • 19/min
• Vital signs • Blood Pressure
• Taken at Room 3 (Bilik Rawatan) • 122/79
at 9:00 am
• Pulse
• Pain score
• 86 bpm
• 4/10
CONT…

• Rhythm • Urine (glucose)

• Regular • NIL
• Volume • Urine (albumin)
• Regular • NIL
• Body weight • SPO2
• 72kg • 97%
 Examination of head and special senses
• Head • Ears • Neck
• No discharge • No discharge • No mumps
• No trauma • No scar • No swelling
• No swelling • No swollen • No tenderness
• No fracture • Nose
• mouth • No swelling
• No ulcer • No discharge
• No scar • Symmetry
• Dark colour lips (black)
• Eyes
• Dry lips
• Normal eyesight
• Throat
• Conjunctiva pink
• No thyroid enlargement
• No cataract
• No tonsil enlargement
• Tongue
• pink
Chest

• Heart • Lungs
• Inspection
• Inspection
• No trauma sign
• No trauma sign • No scar
• No scars • Symmetric chest expansion(normal)
• No deformity • No deformity
• Palpation • Palpation
• No tenderness
• Apex beat present
• Percussion
• No tenderness • No dullness
• Percussion • No hyperresonance
• Dullness • Right and left lungs normal resonance sound
• Auscultation
• Auscultations
• No Ronchi
• Air entry are equal • No crepitation
• No murmur • Equal air entry
CONT…

• Abdomen
• Inspection • Percussion
• No deformity • No shifting dullness
• No scar • Good tympanic sound
• No trauma sign • No resonance present
• No discharge • Auscultation
• Palpation • Normal bowel sound
• Tenderness in epigastric • Bowel sound 11/min
• No palpable mass
CONT…

• Nervous • Upper extremities

• Positive tendon reflex
• Positive plantor reflex
• Positive pin test reflex
• Lower extremities
• No deformity
• Good sensation
• No laceration
• Capillary refill time less than 2 seconds
• No deformity
• Good sensation
• No laceration
• Capillary refill time less than 2 seconds
CONT…

• Genital
• Normal
• No discharge
• No bleeding
• No mass
• Rectum
• Normal
• No ulcer
• No discharge
• No hemorrhoid
Summary of important and relevant finding
DIAGNOSIS

• Provisional diagnosis • Differential diagnosis

• Acute gastritis • Appendicitis
• Food poisoning
INVESTIGATION

• Ultrasound • Stool test

• Check for marked transmural • To check for antibodies titers
gastric wall thickening that fight H.pylori bacteria
• endoscopy
• Examine the stomach lining
• Get a sample biopsy to test for
infection
MANAGEMENT

• Acute gastritis • H. Pylori infection

• Antacid • Triple regimen
• Mixture magnesium Trisilicate (MMT) 30 Mls
stat
• Proton Pump
• Proton Pump Inhibitor + amoxicillin +
• Omeprazole clarithromycin
• Esomeprazole
• Pantoprazole
• Inhibitor
• Adult (oral) = 20mg BD • Pantoprazole 20mg BD + Amoxicillin
500mg TDS/ flagyl 400mg TDS +
• (IV) = omeprazole/pantoprazole 40mg OD clarithromycin 500mg BD
NURSING INTERVENTION

• Monitor the quantity of food ingestion

• Supply food in portion that are often
• Provide a diet plan that diverse based on his diet plan
Health education and advice to
patient/guardian

• Follow the appointment set by the clinic

• Maintain a balanced diet
• Less or not drink alcohol
• Do not eat foods that can cause irritation
• Take prescribed medicine on covered time, frequency, and dosage as
ordered by doctor