BAHAGIAN 2: RIWAYAT PESAKIT Aduan Utama: Abdominal pain for 1 week The patient was doing a medical check-up at Hospital Kota Tinggi Tinggi at four o'clock in the afternoon. octors ha!e been diagnosed intestinal obstruction disease. There" doctor said the patient should be referred to Hospital #ultan $smail to get the full treatment. The patient was sent there b% an ambulance.
#e&arah en%akit Kini: a( atient atient was apparentl% apparentl% all all right 1 week ago when when he de!eloped de!eloped abdomina abdominall pain - )eneralised - $nte $nterm rmit itte ten nt" coli colick ck% % - *o radiation of of pain b( Also assoc associated iated with !omitin !omiting g for the the past 1 week week - He cla claim ims s that that he he !om !omit its s wha whate! te!er er he he eat eats s - +omits mits food food parti particl cles es and and flui fluids ds - *o bile content c( ,oss ,oss of appe appetit tite e ,A ,A ( for 1 week week d( Abdomi Abdominal nal dist distens ension ion for for 1 week week e( *ot *ot redu reduc cing ing f( Unab Unable le to to / / for for the the past past 0 da% da%s - atien atientt claims claims that that he he initia initiall% ll% had had diarr diarrhea hea for for the the past past da%s da%s - Then Then foll follow owing ing that that he had had no no mor more e / / - /ut /ut he he sti still ll does does pass pass flat flatus us
#e&arah en%akit ,alu: Termasuk alahan ubatan( a( Alle Allegi gic c to to sea seafo food ods s
#e&arah Keluarga: 1. 2irst 2irst son son out of of T34, T34,+4 15 ( sibli siblings ngs 5. *o histor% histor% of maligna malignancies ncies among among famil% famil% members members #e&arah #osial: 1. He smok smokes es for for more more than than 06 06 %ears %ears 5. He is not an an alcoh alcohol ol cons consume umer. r. . He is non non $+ $+U U 0. He li!es li!es with with wife wife and has 2$+4 2$+4 7 ( children children #e&arah 8): a( *il
#e&arah embedahan ahulu: a( Histor% Histor% of cataract cataract operat operation ion for for left left e%e e%e b( *o oth other er ope opera ratio tions ns
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN: 1. a) *) ) d)
Cardioa!"#$ar !%!&'( Nor(a$ DRNM +d#a$ r%&,( o (#r(#r) S1S2 or(a$ /i&, r'0#$ar r%&,( No ,'!& ai /,i$' *r'a&,i0
2. a) *) ) d) ') 8)
R'!ira&or% !%!&'( Nor(a$ R'!ira&io ra&' 234(i P#$!' ra&' 564(i No d%!'a No /,''7i0 No !&ridor
9. a) *) ) d) ')
Cir#$a&or% !%!&'( Nor(a$ No a$' No %ao!' No di77i'!! No aa'(ia !%(&o(
. a) *) )
S"'$'&a$ !%!&'( Nor(a$ Po!i&i' (o&or r'8$'; Br#d7i!"i !i0 '0a&i'
<. a) )
E;r'&or% !%!&'( Bo/'$ !o#d !$#00i!, Kid'% a$a*$'
6. a) *) ) d)
M#!#$o!"'$'&a$ !%!&'( Nor(a$ Po!i&i' (o&or r'8$'; No (#!$' d%!&ro,% No &'d'r or /ar(
5. a) *) )
Edori' !%!&'( Nor(a$ No &,%roid 0$ad '$ar0'('& No &r'(or
KHAS UNTUK PEDIATRIK: #e&arah Kelahiran: *one
#e&arah emakanan: *one
#e&arah Tumbesaran: *one
IMUNISASI: 9enis $munisasi
Tarikh
9enis $munisasi
/)
T ; olio os 1
Hepatitis / os 1
T ; olio os 5
Hepatitis / os 5
T ; olio os
Hepatitis / os
T ; olio /ooster 1
ampak
T ; olio /ooster 5
,ain-lain imunisasi(
BAHAGIAN 9: PEMERIKSAAN =I>IKAL
1. emeriksaan Am: a( b( c( d(
: alert : people"time"place : no sei=ures" no hemiparesis : able to mo!e with mild pain
5. Tanda +ital enilaian kesakitan #uhu /adan Kadar ernafasan Tekanan arah Kadar *adi Bitma *adi /erat /adan U&ian Urin )lukosa
: 5>16 : ?.6@ : 56 breaths per minute : 106>?1 mmHg : ? beats per minutes : Begular : 7? kg : C.
Tarikh
. emeriksaan Kepala dan #istem eria Khas: termasuk
refleD to light -*o periorbital pain e(
f( *eck i( $nspection -normal -&ugular !ein normal ii( alpation -no th%roid gland enlargement -no trachea de!iation
/ahagian ada:
Ja�: clear
1( $nspection a( *ormal b( *o scar c( *o wound > bleeding d( *o barrel chest e( *o deformit% 5( alpation a( *ormal b( *o bone fracture c( ApeD beat normal ( Auscultation a( *ormal b( *o gallop sound c( #1#5 normal d( B*< ual B%thm *o
Par#-ar#: clear
1( alpation a( *ormal b( #%mmetrical while breathing
5( ercussion a( *ormal b( Besonance ( Auscultation a( *ormal b( *o rhonci c( *o whee=ing d( *o crepitus e( Air entr% eFual bilateral
A*do(':
1( $nspection a( *ormal b( *o scar c( *o an% skin disease 5( alpation a( Tense" generalised tenderness b( ositi!e guarding c( ositi!e rigidit% ( ercussion a( *ormal b( ullness c( *o shifting dullness d( *o fluid thrills 0( Auscultation a( /owel sound sluggish
#istem #araf: 1( ositi!e tendon refleD 5( ositi!e plantar refleD ( #ensor% function 0( #uperficial touch normal 7( ain when prick
Anggota Atas dan /awah: 1( *o deformiti 5( *o clubing fingers ( *o !aricose !ein 0( ositi!e all mo!ement fleDion" eDtension"abduction etc( 7( Hand dominance : Bight
,ain-lain: termasuk )enitalia" Bektum dan sebagain%a( 1(
)enital a( *o swelling b( Tender c( *ot reducible
5(
Bectum a( *ormal b( *o per rectum mass c( *o discharge d( *o rectum prolapse e( *o hemorrhoid
BAHAGIAN : RINGKASAN PENEMUAN YANG PENTING DAN RELE?AN
BAHAGIAN <: DIAGN@SIS iagnosis #ementara: $ntestinal bstruction iagnosis erbe=aan: 1. Acute holec%stitis 5. Acute Apendicitis . erforated eptic Ulcer 0. Acute ancreatitis
BAHAGIAN 6:
PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN RELE?AN
B$ood T'!&: 1.) FBC ( Full Blood Count ) - /a! 'r8or('d &o d'&'& a*or(a$i&i'! i *$ood. T,'!' &'!&! /'r' a$!o od#&'d &o d'&'& / ,'&,'r &,' a&i'& ,a! ('dia$ odi&io! or o&. E;a($' H* '!&i(a&io &'!& &o !'' i8 a ir'a!' or d'r'a!' i ,'(o0$o*i Result: a) WBC +W,i&' *$ood '$$) *) RBC +R'd *$ood '$$) ) H0* +Ha'(o0$o*i) d) H& +H'(a&ori&) ') P$a&'$'&
: 16.3139 L +<.2 - 12.) : 2.69136 L + .<3 - <.<3) : 1.< 04dL +19.3 - 15.3) : 1F.L4L +3.9F &o 3.<1) : 99F ; 1394#L +1<3-13)
2.) RP ( Renal profile) - d'&'& a% a*or(a$i&i'! o8 r'a$ 8#&io ad &o "o/ &,' '$'&ro$%&' *a$a' i &,' *od% o8 &,' a&i'&. Result: a) Cr'a&ii' #r'a *) Sodi#( ) Po&a!!i#( d) Ur'a
: FF ((o$4L : 19< ((o$4L : .2 ((o$4L : .9 ((o$4L
+62-136) +19<-1<) +9.<-<.3) +1.5-.9)
9.) A*do(ia$ Ra% &o d'&'& a% a*or(a$i&i'! i &,' a&i'&! a*do(' Result: Di$a&'d !(a$$ *o/'$
BAHAGIAN 5: PENGURUSAN atient in the ward accompanied b% his second and fifth daughter at about ?:66 pm from 4mergenc% epartmant Hospital #ultan $smail refer case from Hospital Kota Tinggi(. atient was going through an operation G ,imited Bight Hemicolectom% because patient was in the emergenc% condtion at the ti me when sent to the 4mergenc% epartment. The operation was done at about C.66 pm. 1. atient was admitted to be in male surgical ward A. 5. atient was placed in the room as the patientIs condition which is not se!ere . . atient was rest in bed and taking patient histor% as the main complaint" histor%. 0. atients undergoing general eDamination and ph%sical eDamination inspection" percussion" palpation and auscultation(. 7. +ital signs such as bod% temperature" blood pressure" pulse rate and respirator% rate were recorded. . atient was admitted to be nil b% mouth */<( and inserted intra!ena infusion with 2UB 0 ( pints" 5 *ormal #aline" 5 eDtrose #aline. ?. atient was kept in B%les tube to be free flow and follow b% 2UB 0 ( hourl% aspirate. C. atient was obser!ed for checking abdominal distension. J. ,aborator% in!estigations were carried out as 2ull /lood ount 2/ (" Benal rofile B (. Pr'ara&io ad Car' o8 Pa&i'&! B'8or' S#r0'r% +Pr' @'ra&i' Car') 1. escribes the surgical procedure laparotom% ad!antages and complications deri!ed from patient. 5. Ad!ising the patient not to worr% to face surger% . btain consent from the patient or person responsible 0. onfirm written consent for the procedure from the patient or person responsible 7. oing in!estigation /use" 2ull /lood ount" and iagnostic $maging. . repare blood and )roup ross
Pa&i'& Car' A8&'r S#r0'r% +Po!& @'ra&i' Car') 1. Becei!e patient from the operating theatre room 5. onsuming !ital sign e!er% *4 1 ( hour to monitor de!elopment as the first postoperati!e patient . Keep *il /%
Tr'a&('& ('dia&io! 0i' 1. atient was gi!en medications such as: $+ 2entan%l J6mcg stat and Action : acts as anesthesia and analgesic to patient. #ide effects : abdoment pain" agitation" constipation" headache" dr% mouth" !omiting $+
N#r!i0 ar' a( monitoring !ital signs of blood pressure" pulse and respiration and bod% temperature. b( strictl% obser!ing and recording $nput utput chart c( obser!e and detect an% bleeding d( maintain patient in good comfortable and safet% condition e( maintenance of intra!ena infusion f( patient h%giene as nails" hair" bowel and bladder g( pro!ide appropriate nutritional diet" High protein diet.
BAHAGIAN : NASIHAT RELE?AN KEPADA PESAKIT4PENJAGA 1. atient reFuires adeFuate rest to the healing of wounds due to surger% 5. atient should keep diet b% eating foods that are nutritious and high in protein to promote wound healing" such as fish . atient is not allowed to appl% water to pre!ent infection of surgical wounds in the !icinit% 0.
LAP@RAN RE=LEKTI=: /erikan komen mengenai pembela&aran 8 implikasi pengurusan kes ini %ang telah diperolehi daripada pengka&ian kes ini(
engurusan kes:
/aik
,emah
Befleksi pembela&aran %ang diperolehi daripada pengka&ian kes i ni: #a%a praktikal di wad pembedahan di Hospital #ultan $smail selama satu bulan. #a%a mendapati bahawa terdapat ban%ak prosedur %ang perlu dilakukan sebelum pembedahan" semasa pengendalian dan selepas pembedahan. esakit %ang sa%a diambil sebagai kes clerking sa%a" dia dimasukkan wad dari 10 2ebruari hingga disca& pada 57 2ebruari 5610. esakit telah melalui right hemicolectom%" eDploratom% laparatom% untuk stoma dan laparotom% untuk resection usus dan stoma. #a%a bela&ar bahawa tidak ada cara mudah untuk men%embuhkan pen%akit halangan usus tetapi ia boleh diketahui dengan menilai pemeriksaan dan siasatan setiap hari untuk mengetahui masalah perut dengan lebih lan&ut.
KURSUS DIPL@MA PEMBANTU PERUBATAN =@RMAT PEMARKAHAN CASE CLERK!" Na(a P'$a&i,:
No. Ma&ri": ..
Ta,#: S'('!&'r: Ka/a!a P''(a&a: ... Bi$. 1 5
0 7
?
C J
P'r"ara Keterangan eribadi esakit Ri/a%a& P'!a"i&: 5.1Aduan Utama 5.5#e&arah en%akit Kini 5.#e&arah en%akit ,alu 5.0#e&arah Keluarga 5.7#e&arah #osial ,ain5 %ang berkenaan( P'('ri"!aa =i7i"a$: .1emeriksaan Am .5 Tanda-tanda +ital .Kepala 8 4>4*T .0ada 9antung( .7ada aru-paru( .Abdomen .?#istem #araf .CAnggota Atas 8 /awah .J,ain-lain seperti genitalia 8 rektum" dll(
Waara <
S"or
2<
2<
< < < 23 < < 133
Tandatangan emeriksa
: MMMMMMMMMMMM.MMMMM
*ama
: MMMMMMMMMMM.MMMMMM
Tarikh
: MMMMMMMMMMMMMMMMM
Ca&a&a
KURSUS DIPL@MA PEMBANTU PERUBATAN SENARAI SEMAK CASE PRESE!#A#$! Na(a P'$a&i,:
No. Ma&ri": ....
Ta,#: S'('!&'r: Ka/a!a P''(a&a: ....... Bi$.
P'r"ara
Waara
1
embentangan keterangan peribadi pesakit %ang tepat
5
embentangan riwa%at pesakit %ang lengkap
0
embentangan diagnosis 8 diagnosis perbe=aan %ang tepat
7
adangan pen%iasatan %ang penting 8 rele!an
embentangan pengurusan pesakit %ang tepat dan lengkap JUMLAH
PELAKSANAAN M'(#a! Bai" L'(a, "a
1
5
1
1 5
13
S"or: ......... ; 133 .......................... 13
Tandatangan emeriksa
: MMMMMMMMMMMM.MMMMM
*ama
: MMMMMMMMMMM.MMMMMM
Tarikh
: MMMMMMMMMMMMMMMMM
S"or
Ca&a&a
