Tel

HOSPITAL MACHANG
Jalan Pasir Puteh,
18500 Machang,
Kelantan Darulnaim.

Fax
E-mail

: 09 975 2533 / 2534

: 09 975 1633 / 1634 / 1635
: 09 974 1300
: 09-9752470
: hosmac@klt.moh.gov.my

Ruj Surat Kami :

Ruj Surat Tuan :
Tarikh
: 06.06.2016

--/16

LAPORAN PERUBATAN (MEDICAL REPORT)

KEMENTERIAN KESIHATAN MALAYSIA
Butiran Pesakit (Patient Particulars):
Nama pesakit
(Name of Patient)
No K/P
(I/C No)

MOHD JUNAIDI BIN MOHAMAD

Baru (New)
Lama(Old)

No. Passport (Passport No)

850531-03-5589
-

MRN

3039/16

Umur (Age)

31 YEARS OLD

Jantina (Sex)

Lelaki (Male)

Perempuan (Female)
Tarikh masuk wad atau menerima rawatan buat
kali pertama
(Date of admission or receiving treatment for the
first time)

27/3/2016

Jabatan Kecemasan
Tempat menerima
rawatan
(Place where patient
received treatment)

(Emergency Dept.)

Klinik Pakar
(specialist clinic)

Wad
(Ward)

Tarikh discaj dari wad atau meninggal dunia

(date of discharge or death)
Pg. 1 , Laporan Perubatan , Hospital Machang, Kelantan

03/05/2016

Disiplin (Discipline)

Pg. 2 , Laporan Perubatan , Hospital Machang, Kelantan

ORTHOPAEDIC/MEDICAL

Sejarah (History):
(Including Presenting Complaints, History of Presenting complaints, Past Medical History, Family
History, Social History and Occupational History, Review of systems, Medical Records reviewed)
This is 31 years old Malay gentleman.
This patient had underlying
1) Neurofibrosis since 15 years old
2) Terminal stage left pelvis neurofibrosarcoma under follow up Hospital
Raja Perempuan Zainab II (HRPZ II) (Orthopaedic and Oncology team)
- He was diagnosed to had this disease on August 2015 at HRPZ II
- Operation was done on November 2015 for removal of tumor.
- He was planned for radiotherapy after operation, however patient
was not fit to continue with radiotherapy and planned for palliative
care.
Patient had multiple admission to Hospital Machang since Mac 2016.
Initially patient was admitted
First admission on Mac 2016 for
1) Sepsis secondary to infected ruptured tumor.
Treatment was given to patient in view of infected wound over tumor
area.
Daily dressing and antibiotic was given to patient.
Case was discuss with orthopaedic team from HRPZ II and decide for
palliative care in view of rapid progression of the tumor.
Patient was refer to health clinic for nursing home care.
Second admission On April 2016 patient was admitted again for
1) Aspiration pneumonia
- Patient was completed iv Rocephine 1g od and iv flagyl 500mg tds
2) Anaemia secondary to underlying malignancy
- Patient was transfused total3 pint packed cell
3) Hypovolomic shock secondary to dehydration and aspiration
pneumonia
- Patient was on iv infusion inotrope for 3 days.
4) Bed sore grade 3-4 in view of patient bed ridden at home
- Daily dressing was done in ward
Third admission on April 2016 patient was admitted again nad treat as
1) Septicaemic shock secondary to Hospital Acquired Pneumonia
- Patient was started on IV Fortum 1g TDS and blood pressure was
supported with IV infusion noradrenaline
- Clinically patient was not improved with strong antibiotic and
inotrope.
- Patient was deteriorate on day 4 admission and reduce
consciousness. Family member understand his conditions and
decide for not active resuscitation.
- Patient was passed away on 3/5/2016 at 10:11pm.

Pemeriksaan Fisikal (Physical Examination):

(Including general assessment, Eye, ENT, oral cavity, Respiratory System, Cardiovascular System,
Abdomen, Genitourinary, Central Nervous System, Musculoskeletal, Mental Health Status and
Others)

Pg. 3 , Laporan Perubatan , Hospital Machang, Kelantan

On admission
Patient was alert, conscious , GCS E4V5M6 ( bedridden and weak)
Vital signs : Blood Pressure: 108/53
.
Pulse Rate
: 127
Temperature
: 37.3
Cardiovascular System
: dual rhythm no murmurs
Respiratory System
: air entry equal, transmitted sound
Abdominal examination
: soft , non-tender, tumor extended over left side
of abdomen.
Ruptured tumor at left side measure 6x5cm associated with pus discharge.
Right gluteal pressure sore measure 4 x 5 cm
Sacral sore with minimal slough measure 2x1cm
Investigations :
TWC
Hb
Plt
Ure
a
Na
K
Crea
t
AST
ALT
ALP

27/3
41.8
10.7
379
5.9

30/3
32.6
8
9.10
378
3.5

24/4
29.1
7
8.1
298
3.0

119
5.9
26

126
4.6
17

120
4.0
23

45
11
211

27/4
20.2
8
6.6
127

28/4
31.8
2
11.7
126

30/4
25.5
8
9.60
109

35
5
65

ECG: Sinus Rhythm

CXR: Bilateral Perihilar Hazziness which suggest of Aspiration Pneumonia

Diagnosis (Diagnosis)

Pg. 4 , Laporan Perubatan , Hospital Machang, Kelantan

1.
2)
3)
4)

Terminal stage left pelvis neurofibrosarcoma

Sepsis secondary to infected ruptured tumor.
Bed sore grade 3-4
Septicaemic shock secondary to Hospital
Acquired Pneumonia

Rawatan (Treatment)

Rumusan prosedur yang dijalankan ke atas

pesakit
(summary of procedures carried out on
patient)

Patient was started on IV Fortum 1g TDS

Blood pressure was supported with IV
infusion noradrenaline
Clinically patient was not improved with
strong antibiotic and inotrope.
Patient was deteriorate on day 4
admission and reduce consciousness.
Family member understand his
conditions and decide for not active
resuscitation.
Patient was passed away on 3/5/2016 at
10:11pm.

Preskripsi ubat-ubat yang diberikan kepada

pesakit
(drugs and other medicaments prescribed
to patients)
Cuti sakit/sekolah (Medical certificate/school leave) (MC No)
Dari (From) :

Hingga (To) :

Surat kerja ringan yang diberikan (light duty given)

Dari (From) :

Pg. 5 , Laporan Perubatan , Hospital Machang, Kelantan

Hingga (To) :

Doktor Yang Merawat

(patient was attended by)

DR. FARAHWAHIDA BINTI OTHMAN

Laporan disediakan oleh (Report prepared by):

Nama (Name)

No. K/P(I/C No)

Jawatan(Designation)
Kelulusan(Qualification)
Jabatan (Department)

DR. FARAHWAHIDA BINTI IOTHMAN

880909-02-5030
PEGAWAI PERUBATAN UD44
MD(UKM)
KECEMASAN/PERUBATAN

Cop rasmi Hospital (Official Hospital Stamp)

Tarikh (Date)

..
( DR FARAHWAHIDA BINTI OTHMAN)
(No. Pendaftaran Penuh MPM :61663
)
Pegawai Perubatan UD44
Hospital Machang,
18500 Machang,
Kelantan.

Pg. 6 , Laporan Perubatan , Hospital Machang, Kelantan

06/06/2016

Adalah disahkan laporan ini

di keluarkan melalui
Unit Rekod Hospital Machang

Pg. 7 , Laporan Perubatan , Hospital Machang, Kelantan

Pg. 8 , Laporan Perubatan , Hospital Machang, Kelantan

Pg. 9 , Laporan Perubatan , Hospital Machang, Kelantan