CLERKING CASE

MOHD IKHSAN BIN KHURAI RAIRY

850324-08-5647
BPP 2005-0514
: 15/1/07
K1
ALOR STAR KEDAH

PATIENT BIODATA

REGISTER NUMBER: 477423

NAME : MUHAMMAD IRFAN BIN ABU WAHAB
RACE : MALAY
OCCUPATION : STUDENT
ADDRESS : NO 9,FELCRA BELIMBING TOLAK 06300,KUALA
NERANG KEDAH
I/C NUMBER : 900724-02-5523
AGE : 16 YEARS
GENDER : MALE
RELIGION : ISLAM
PATIENT HISTORY

C/O
o Pesakit mengadu sakit perut. ( 10 / 7 )

HOPI
o Low grade Fever x6/7
o Abdominal pain from umbilical radiating to right iliac fosa RIF.
o Colicky pain
o Lost of appetite x(5/7)
o Vomiting

PMHX

o Nil
o Never taked traditional treatment

PSHX
o Nil

FHX
o No family history of simular problem
o No family history of cronic medical case such as diabetis melitus,heart
problem,hipertension,renal failure,asthma

SHX
o Form 5 student at Sekolah Menengah Kuala Nerang.
o Not active in sport
o Never take alchohol
o Never smoking
ON EXAMINATION

GENERAL INVESTIGATION ( IPPA : HEAD TO TOE )

o Vital Sign
BP : 130 / 80mm/Hg
PR : 120 minit
TEMP : 39 C

o Pink

o Alert

o Concious

o No sinusitis

o No tachypnoea

o Head normal,no head injury.

o Eyes no blured vision,no diplopia.

o Ears No discharge,no tinnitus,no vertigo

o Nose No discharge,no alergic,no epistaxis

o Throat no sore throat,no swollen gland and cough

o Neck no stiffness,no sweling@redness.

o Respiratory system no creptitation, normal expirasion and

inspirasion, normal respirasion rate,no stridor dan wheezing, normal
chest movement.

o Cardiovascular system ( CVS ) dual rhythm no murmur ( DRNM )

 Abdominal investigation ( IPPA )

o INSPECTION
No swollen @ abnormal swelling
No surgical scar

o PALPATION
Tender at right iliac fossa.
No hepatomegali
No spleenomegali

o PERCUSSION
Resonan

o AUSCULTASION
Active bowel sound

PHYSICAL FINDING

o Mc Burney Point ask the patient to show the part of pain with one
finger.if patient show at Mc burney point,the test is positive.

o Rovsing signs pressure in the left iliac fossa causes pain in the right
iliac fossa.

o Rebound Tenderness pressure at right iliac fossa with fingers slowly

and release it fastly.At the same time,look at patient face and ask the
patient did he feel any pain and when,at the time of pushing or release.

o Tanda PSOAS patient feel pain when pull up right leg againts our
hand or ask the patient to laydown with left lateral position and ask the
patient to pull the right leg to the abdomen.

PHYSICAL EXAMINATION

o Per rectum
o abdominal palpation
o Rebound tenderness ( + Ve )
o Rovsing Signs( + Ve )
o PSOAS signs( + Ve )
 PRE DIAGNOSIS :

o Acute appendicitis

DIFFRENTIAL DIAGNOSIS :
o Urinary track infection( UTI )
o Pankreatitis
o Warm Colic
o Cystitis

INVESTIGATION & RASIONALISE

Urine FEME
o To find wether there is a bacteria insist or not in the urine specimen.

FBC ( Full Blood Count )

o To count haemoglobin level and find out if patient had anaemia or
not.also to find Total White Difference Count (TWDC)

BUSE ( Blood Urea Serum Electrolytes )

o To find out urea,sodium,potassium and chloride cointain wether there
is in normal rate or not.

RBS ( Random Blood Sugar )

o To inspect glucose level in the blood.

GXM ( Group X Maching )

o To find out patient blood type.

LAB INVESTIGATION RESULT

FBC ( Full Blood Count )

REFERENCE
RESULT UNIT RANGE /
COMMENTS
WBC 9.4 10^3/UL 5.2 12.4
RBC L 4.35 10^6/UL 4.7 6.1
HGB L 13.1 g/DL 13.5 18.0
 PLT 222.0 10^3/UL 140.0 400.0

UFEME

SUGAR NEGATIF
ALBUMIN NEGATIF
MICROSCOPIC EXAMINATION PC 0 4

BUSE ( Blood Urea Serum Electrolytes )

UREA & ELECTROLYTES

RESULT UNIT NORMAL RATE
UREA 4.43 Mmol/L 1.70 8.30
SODIUM 136.70 Mmol/L 135.00 152.00
POTASSIUM 2.91 Mmol/L 3.50 5.40
CHLORIDE 102.80 Mmol/L 96.00 108.00

DIAGNOSIS ACUTE APPENDICITIS

MANAGEMENT

SURGICAL WARD ( K1 )

o Admition
o Vital sign monitoring
o Head to toe phsyical examination perfomed
o Iv infusion Normal Saline 0.9 %
o Intake output chart monitoring
o Hygernic care to prevent infection
o Drugs.
I/M Voltaren 15mg stat
I/V Cefobid
I/V Flaygyl
I/V Dextrose 5%
I/V Normal saline
 PRE OP

o Physical and mental preparation.

o Consent form to fill.
o Patient preparation
Skin prep
o Monitoring vital sign
o Nil by mouth at least 6 hour before operation
o Antibiotic given via i/v for prophylaxis.
o Chest x-ray
o Empty bladder

POS OP

o Vital sign monitoring

o Patient rehabitation
patientreassure and immobilisasi
i/v infusion care
o drugs
Antibiotik I/V Cloxacillin 500g QID
Symptomatic treatment
o Routine investigation
o Wound care-daily dressing
o Nursing care
Patient position ( recumben or supine )
Hygernic care
Well balance diet
Exercise

HEALTH EDUCATION

Come again to continue treatment.

Go to hospital immediately if there complication to the wound such as
bleeding,swollen.
Eat more fibre contain food
Do healthy life style,dont smoking,dont take alcohol
 Dont do any heavy activities.
Dont scrub any lotion or oil that not recommend by physician