BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:
Abdominal pain for 1 week
The patient was doing a medical check-up at Hospital Kota Tinggi at four o'clock in
the afternoon. Doctors have been diagnosed intestinal obstruction disease. There,
doctor said the patient should be referred to Hospital Sultan Ismail to get the full
treatment. The patient was sent there by an ambulance.
Sejarah Penyakit Kini:
a) Patient was apparently all right 1 week ago when he developed abdominal
pain
- Generalised
- Intermittent, colicky
- No radiation of pain
b) Also associated with vomiting for the past 1 week
- He claims that he vomits whatever he eats
- Vomits food particles and fluids
- No bile content
c) Loss of appetite ( LOA ) for 1 week
d) Abdominal distension for 1 week
e) Not reducing
f) Unable to BO for the past 4 days
- Patient claims that he initially had diarrhea for the past 3 days
- Then following that he had no more BO
- But he still does pass flatus
Sejarah Penyakit Lalu:
(Termasuk alahan ubatan)
a) Allegic to seafoods
Sejarah Keluarga:
1. First son out of TWELVE ( 12 ) siblings
2. No history of malignancies among family members
Sejarah Sosial:
1. He smokes for more than 40 years
2. He is not an alcohol consumer.
3. He is non IVDU
4. He lives with wife and has FIVE ( 5 ) children
Sejarah O&G:
a) Nil
Sejarah Pembedahan Dahulu:
a) History of cataract operation for left eye
b) No other operations

KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1.
a)
b)
c)
d)

Cardiovaskular system
Normal
DRNM (dual rythm no murmur)
S1S2 normal with regular rythm
No chest pain while breathing

2.
a)
b)
c)
d)
e)
f)

Respiratory system
Normal
Respiration rate 20/min
Pulse rate 76/min
No dyspnea
No wheezing
No stridor

3.
a)
b)
c)
d)
e)

Circulatory system
Normal
No pale
No cyanose
No dizziness
No anaemia symptom

4.
a)
b)
c)

Skeletal system
Normal
Positive motor reflex
Brudzinski sign negative

5.
a)
c)

Exrectory system
Bowel sound sluggish
Kidney palpable

6.
a)
b)
c)
d)

Musculoskeletal system
Normal
Positive motor reflex
No muscle dystrophy
No tender or warm

7.
a)
b)
c)

Endocrine system
Normal
No thyroid gland enlargement
No tremor

KHAS UNTUK PEDIATRIK:

Sejarah Kelahiran:
None

Sejarah Pemakanan:
None

Sejarah Tumbesaran:
None

IMUNISASI:
Jenis Imunisasi

Tarikh

Jenis Imunisasi

BCG

DPT + Polio Dos 1

Hepatitis B Dos 1

DPT + Polio Dos 2

Hepatitis B Dos 2

DPT + Polio Dos 3

Hepatitis B Dos 3

DPT + Polio Booster 1

Campak

DT + Polio Booster 2

(Lain-lain imunisasi)
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
1. Pemeriksaan Am:
a)
b)
c)
d)

Mental status
Orientation
Neuromotor
Movement

: alert
: people,time,place
: no seizures, no hemiparesis
: able to move with mild pain

2. Tanda Vital
Penilaian kesakitan
Suhu Badan
Kadar Pernafasan
Tekanan Darah
Kadar Nadi
Ritma Nadi
Berat Badan
Ujian Urin Glukosa

: 2/10
: 37.0C
: 20 breaths per minute
: 140/71 mmHg
: 76 beats per minutes
: Regular
: 57 kg
: 8.3

Tarikh

3. Pemeriksaan Kepala dan Sistem Deria Khas:

(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)
a) Head
i) Inspection
-normal
-no tumor
-no moon face
-no external skull
b) Ears
i) Inspection
-normal
-clean ; no discharge
-no bleeding
-no scar
c) Nose
i) Inspection
-normal
-clean
-no discharge
d) Eyes
i) Inspection
-normal
-no racoon eyes
-no uprolling eyes
-symmetrical and same size
ii) Palpation
-Pink
-No jaundice
-Dilate/reflex to light
-No periorbital pain
e) Mouth
i) Inspection
-Normal
-Pink
-Not pale
-hydration fair
-no ulcer ; no bleeding
f) Neck
i) Inspection
-normal
-jugular vein normal
ii) Palpation
-no thyroid gland enlargement
-no trachea deviation

Bahagian Dada:
Jantung:
clear

1) Inspection
a) Normal
b) No scar
c) No wound / bleeding
d) No barrel chest
e) No deformity
2) Palpation
a) Normal
b) No bone fracture
c) Apex beat normal
3) Auscultation
a) Normal
b) No gallop sound
c) S1S2 normal
d) DRNM ( Dual Rythm No Murmur )

Paru-paru:
clear

1) Palpation
a) Normal
b) Symmetrical while breathing
2) Percussion
a) Normal
b) Resonance
3) Auscultation
a) Normal
b) No rhonci
c) No wheezing
d) No crepitus
e) Air entry equal bilateral

Abdomen:

1) Inspection
a) Normal
b) No scar
c) No any skin disease
2) Palpation
a) Tense, generalised tenderness
b) Positive guarding
c) Positive rigidity
3) Percussion
a) Normal
b) Dullness
c) No shifting dullness
d) No fluid thrills
4) Auscultation
a) Bowel sound sluggish
Sistem Saraf:
1)
Positive tendon reflex
2)
Positive plantar reflex
3)
Sensory function
4)
Superficial touch normal
5)
Pain when prick
Anggota Atas dan Bawah:
1)
No deformiti
2)
No clubing fingers
3)
No varicose vein
4)
Positive all movement (flexion, extension,abduction etc)
5)
Hand dominance : Right

Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
1)

Genital
a)
No swelling
b)
Tender
c)
Not reducible

2)

Rectum
a)
Normal
b)
No per rectum mass
c)
No discharge
d)
No rectum prolapse
e)
No hemorrhoid

BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

BAHAGIAN 5: DIAGNOSIS
Diagnosis Sementara:
Intestinal Obstruction
Diagnosis Perbezaan:
1. Acute Cholecystitis
2. Acute Apendicitis
3. Perforated Peptic Ulcer
4. Acute Pancreatitis

BAHAGIAN 6:

PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

RELEVAN

Blood Test:
1.) 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 an increase or decrease
in hemoglobin
Result:
a)
WBC (White blood cell)
b)
RBC (Red blood cell)
c)
Hgb (Haemoglobin)
d)
Hct (Hematocrit)
e)
Platelet

: 16.8010^3 L (5.2 - 12.4)

: 2.6310^6 L (4.50 - 5.50)
:
14.5 g/dL (13.0 - 17.0)
:
19.4L/L (0.39 to 0.51)
: 339 x 10^3/uL (150-410)

2.) RP ( Renal profile) - detect any abnormalities of renal function

and to know the electrolyte balance in the body of the patient.
Result:
a)
Creatinine urea
b)
Sodium
c)
Potassium
d)
Urea

: 99 mcmol/L
: 135 mmol/L
: 4.2 mmol/L
: 8.3 mmol/L

(62-106)
(135-145)
(3.5-5.0)
(1.7-8.3)

3.) Abdominal X Ray to detect any abnormalities in the patient's abdomen

Result:
Dilated small bowel

BAHAGIAN 7: PENGURUSAN
Patient in the ward accompanied by his second and fifth daughter at about 7:00 pm
from Emergency Departmant Hospital Sultan Ismail (refer case from Hospital Kota
Tinggi). Patient was going through an operation Limited Right Hemicolectomy
because patient was in the emergency condtion at the time when sent to the
Emergency Department. The operation was done at about 8.00 pm.
1. Patient was admitted to be in male surgical ward 6A.
2. Patient was placed in the room as the patients condition which is not severe .
3. Patient was rest in bed and taking patient history as the main complaint,
history.
4. Patients undergoing general examination and physical examination
(inspection, percussion, palpation and auscultation).
5. Vital signs such as body temperature, blood pressure, pulse rate and
respiratory rate were recorded.
6. Patient was admitted to be nil by mouth (NBM) and inserted intravena infusion
with FOUR ( 4 ) pints, 2 Normal Saline, 2 Dextrose Saline.
7. Patient was kept in Ryles tube to be free flow and follow by FOUR ( 4 ) hourly
aspirate.
8. Patient was observed for checking abdominal distension.
9. Laboratory investigations were carried out as Full Blood Count ( FBC ), Renal
Profile ( RP ).
Preparation and Care of Patients Before Surgery (Pre Operative Care)
1. Describes the surgical procedure " laparotomy " advantages and
complications derived from patient.
2. Advising the patient not to worry to face surgery
3. Obtain consent from the patient or person responsible
4. Confirm written consent for the procedure from the patient or person responsible
5. Doing investigation Buse, Full Blood Count, and Diagnostic Imaging.
6. Prepare blood and Group Cross Match to replace a lot of blood in case of bleeding
7. Starve the patient as "Nil By Mouth" 6 hours before surgery
8. Intake of vital signs to ensure patient is in stable condition
9. Patient wears surgical gowns and oil cap
10. Send the patient to the operating theatre room (Dewan bedah)

Patient Care After Surgery (Post Operative Care)

1. Receive patient from the operating theatre room
2. Consuming vital sign every ONE ( 1 ) hour to monitor development as the first postoperative patient
3. Keep Nil By Mouth with Intravena Drip.
4. Do normal dressing three times a day ( TDS ) over the laparatomy wound
5. Patient is continued with antibiotics and trace tissue Culture & Sensitivity.
6. Patient is fully rest on the bed.

Treatment medications given

1. Patient was given medications such as:
IV Fentanyl 90mcg stat and OD
Action
: acts as anesthesia and analgesic to patient.
Side effects : abdoment pain, agitation, constipation, headache, dry
mouth, vomiting
IV Morphine 4mg
Action
: acts as analgesics
Side efftects : constipation, itchy skin, headache, dizziness
Nursing care
a)
monitoring vital signs of blood pressure, pulse and respiration and body
temperature.
b)
strictly observing and recording Input Output chart
c)
observe and detect any bleeding
d)
maintain patient in good comfortable and safety condition
e)
maintenance of intravena infusion
f)
patient hygiene as nails, hair, bowel and bladder
g)
provide appropriate nutritional diet, High protein diet.

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Patient requires adequate rest to the healing of wounds due to surgery
2. Patient should keep diet by eating foods that are nutritious and high in protein to
promote wound healing, such as fish
3. Patient is not allowed to apply water to prevent infection of surgical wounds in the
vicinity
4. Make sure that every doctor's appointment with a good compliance.
5. Patient should avoid emotional stress to speed up the healing process
6. Advise the patient to do personal hygiene.

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:

Saya praktikal di wad pembedahan di Hospital Sultan Ismail selama satu bulan. Saya
mendapati bahawa terdapat banyak prosedur yang perlu dilakukan sebelum
pembedahan, semasa pengendalian dan selepas pembedahan. Pesakit yang saya
diambil sebagai kes clerking saya, dia dimasukkan wad dari 14 Februari hingga
discaj pada 25 Februari 2014. Pesakit telah melalui right hemicolectomy, exploratomy
laparatomy untuk stoma dan laparotomy untuk resection usus dan stoma. Saya
belajar bahawa tidak ada cara mudah untuk menyembuhkan penyakit halangan usus
tetapi ia boleh diketahui dengan menilai pemeriksaan dan siasatan setiap hari untuk
mengetahui masalah perut dengan lebih lanjut.

KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE CLERKING
Nama Pelatih:

No. Matrik: ..

Tahun: Semester: Kawasan Penempatan: ...

Bil.
1
2

4
5

6
7

8
9

Perkara
Wajaran
Keterangan Peribadi Pesakit
5
Riwayat Pesakit:
2.1 Aduan Utama
2.2 Sejarah Penyakit Kini
2.3 Sejarah Penyakit Lalu
25
2.4 Sejarah Keluarga
2.5 Sejarah Sosial
(Lain2 yang berkenaan)
Pemeriksaan Fizikal:
3.1 Pemeriksaan Am
3.2 Tanda-tanda Vital
3.3 Kepala & E/ENT
3.4 Dada (Jantung)
3.5 Dada (Paru-paru)
25
3.6 Abdomen
3.7 Sistem Saraf
3.8 Anggota Atas & Bawah
3.9 Lain-lain (seperti genitalia & rektum, dll)
(Mana2 yang berkenaan)
Ringkasan Penemuan Klinikal
5
Diagnosis:
5.1 Diagnosis Sementara
5
5.2 Diagnosis Perbezaan
Penyiasatan Yang Penting & Relevan
Pengurusan:
7.1 Pengendalian awal
7.2 Ubat-ubatan
7.3 Penjagaan kejururawatan
Pendidikan Kesihatan
Laporan reflektif
JUMLAH

Skor

5
20
5
5
100

Tandatangan Pemeriksa

: .

Nama

: .

Tarikh

Catatan

KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK CASE PRESENTATION
Nama Pelatih:

No. Matrik: ....

Tahun: Semester: Kawasan Penempatan: .......

Bil.

Perkara

Wajaran

Pembentangan
keterangan peribadi
pesakit yang tepat

Pembentangan riwayat
pesakit yang lengkap

Melakukan pemeriksaan
fizikal yang lengkap dan
relevan dengan betul
Pembentangan
diagnosis & diagnosis
perbezaan yang tepat

Cadangan penyiasatan
yang penting & relevan

Pembentangan
pengurusan pesakit yang
tepat dan lengkap
JUMLAH

PELAKSANAAN
Memuas
Baik
Lemah
kan

1
2
10

Skor: ......... x 100% = ..........................%

10

Tandatangan Pemeriksa

: .

Nama

: .

Tarikh

Skor

Catatan