KURSUS DIPLOMA PEMBANTU PERUBATANKOLEJ PEMBANTU PERUBATAN

ALOR SETAR

CASE CLERKING

TAJUK : RIGHT INGUINAL HERNIA

NAMA PELATIH : MOHD EIZAIRIE BIN ABDUL MUTALIB

NO. MATRIK : DBMA11-6071

NO. KAD PENGENALAN : 910709-04-5023

TAHUN / SEMESTER : 2 / 2

KAWASAN PENEMPATAN : WAD 3C (PEMBEDAHAN)

HOSPITAL SULTANAH BAHIYAH , ALOR

SETAR, KEDAH DARUL AMAN

KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih : MOHD EIZAIRIE BIN ABDUL MUTALIB

No. Matrik : DBMA11-6071

Tahun : 2 Semester : 2

Kawasan Penempatan : HOSPITAL SULTANAH BAHIYAH

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: AS 00330537 Nombor K/P:

-TIDAK PERLU-

Nama:

-TIDAK PERLU DIISI -

Jantina: Lelaki/ Perempuan* :LELAKI

Bangsa:MELAYU

Pekerjaan:JURUTEKNIK ALARM

Umur:29 THN

Alamat:

-TIDAK PERLU-

No. Tel:

-TIDAK PERLU-

Hospital/Klinik:HOSPITAL SULTANAH BAHIYAH

Tarikh:MASUK WAD:17-01-2013 @ 8.23 AMKELUAR WAD:19-01-2013 @9.10 AM

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama: a) Patients have complained of bumps in his scrotum

b) Bumps more prominent (kelihatan) and growing.

c) Noticed around 8 pm last night (16/01/2013)

d) Referred case from Hospital Jitra for irreducible right inguinal hernia

Sejarah Penyakit Kini:

a) irreducible of the right inguinal hernia

b) able to BO (bowel open) and pass flatus

c) no vomiting

d) swelling increase in size (5cm × 5 cm)

e) otherwise no other symptom

f) PU (pass urine) normal ; no dysuria

g) No h/o trauma

h) No h/o insect bite to the affected area

Sejarah Penyakit Lalu:(Termasuk alahan ubatan)

a) No known allergy to food or any drugs

b) Not taken any traditional drugs or treatment

c) The patient has never had a respiratory problem

d) The patient has not had a contagious disease (penyakit berjangkit)

e) The patient has never had a kidney and urinary disease

f) The patient is not suffering from the disease Diabetes Mellitus

Sejarah Keluarga:

1. Mother i) NIL

2. Father i) NIL

Sejarah Sosial:

a) He has married to Nordina, 27 years old

b) He got 1 children and he was healthy

c) Work as alarm engineer at Indah Water

d) He is social smoker (+/- 5 cigarette per day)

e) He is non alcoholic

Sejarah O&G: a) NIL

KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

1. Cardiovaskular systema) Normalb) DRNM (dual rythm no murmur)c) S1S2 normal with regular rythmd) No chest pain while breathing

2. Respiratory systema) Normal b) Respiration rate – 22/minc) Pulse rate – 77/mind) No dyspnoea, no wheezinge) No stridor

3. Circulatory systema) Normal b) No palec) No cyanosed) No dizzinesse) No anaemia

4. Skeletal systema) Normalb) Positive motor reflexc) Brudzinski sign negative

5. Exrectory system a) Normalb) Bowel sound normalc) Kidney palpable

6. Musculoskeletal systema) Normalb) Muscle reflex positivec) No muscle dystrophyd) No tender or warm

7. Endocrine systema) Normal b) No thyroid gland enlargementc) No tremor

KHAS UNTUK PEDIATRIK:

Sejarah Kelahiran:

Sejarah Pemakanan:

Sejarah Tumbesaran:

IMUNISASI:

Jenis Imunisasi Tarikh Jenis Imunisasi Tarikh

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) Mental status : aware,not confused

b) Orientation : people,time,place

c) Neuromotor : no seizures, no hemiperasis

d) Movement : able to move with mild pain

2. Tanda Vital: (taken at 17/01/2013 @ 9.30 am)

Penilaian kesakitan : 2/10

Suhu Badan : 37°C

Kadar Pernafasan : 22

Tekanan Darah :128/74 mmHg

Kadar Nadi : 77/min

Ritma Nadi : Regular

Berat Badan : 70 kg

3. Pemeriksaan Kepala dan Sistem Deria Khas:(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)

a) Headi) Inspection

-normal-no tumor-no moon face-no external skull

b) Ears i) Inspection -normal -clean ; no discharge -no bleeding -no scar

c) Nosei) Inspection -normal -clean -no discharge

d) Eyesi) Inspection -normal -no racoon eyes -no uprolling eyes -symetrical and same size

ii) Palpation -pink -no jaundice -dilate/reflex to light -no periorbital pain

e) Mouthi) Inspection -normal -pink -not pale -hydration fair -no ulcer ; no bleeding

f) Necki) Inspection -normal -jugular vein normal

ii) Palpation -no thyroid gland enlargement -no trachea deviation

Bahagian Dada:

Jantung:

1) Inspectiona) Normalb) No scarc) No wound/bleedingd) No barrel cheste) No deformiti

2) Palpation a) Normalb) No bone fracturec) Apex beat normal

3) Percussiona) Normalb) No dullness soundc) Resonance

4) Auscultation a) Normalb) No gallop soundc) S1S2 normald) DRNM (dual rythm no murmur)

Paru-paru:

1) Palpation a) Normalb) Symetrical while breathing

2) Percussiona) Normalb) Resonance

clear

Lung clear

3) Auscultationa) Normalb) No rhonkic) No wheezingd) No crepituse) Air entry equal bilateral

Abdomen:

1) Inspectiona) Normal b) No scarc) No any skin disease

2) Palpationa) Normalb) No scarc) Bowel sound normal

3) Percussiona) Normalb) Dullness

4) Auscultationa) Normalb) Bowel sound heared

Sistem Saraf:

1) Positive tendon reflex2) Positive plantar reflex3) Sensory function4) Superficial touch normal5) Pain when prick

Anggota Atas dan Bawah:1) No deformiti2) No clubing fingers3) No varicose vein4) Positive all movement (flexion, extension,abduction etc)5) Hand dominance : right

Clear

Note : Patient was able to move all fingers and the capillary refill is less than 2 seconds, sensation intact.

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

1) Genitala) Swelling 5cm × 5cm at right inguinal region, extending to scrotumb) Tenderc) Not reducible

2) Rectum a) Normalb) No per rectum massc) No discharged) No rectum prolapsee) No hemorrhoid

BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

BAHAGIAN 5: DIAGNOSIS

Diagnosis sementara : Right inguinal hernia - based on the patient's main complaints, and physical examination showed signs of inguinal hernia.

Diagnosis Perbezaan: - 1. Hernia femoralis ( contain bowel) 2. Incomplete Descending Testis

3. SpermatoceleBAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

Scrotum is growing and tender

RELEVAN

1) Patient is asked to cough to see how the bumps (bonjolan).

2) 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) : 9.07×10^3 µL (5.2 – 12.4.)b) RBC (Red blood cell) : 493×10^6 µL (4.50-5.50)c) Hb (Haemoglobin) : 14.3 g/dL (13.0 -17.0)d) Platelet : 271 x 10^3/uL (150-410)

3) RP ( Renal profile) - detect any abnormalities of renal functionand to know the electrolyte balance in the body of the patient.

Result:a) Creatinine urea : 75 µmol/Lb) Sodium : 139 mmol/L (133-145)c) Potassium : 3.9 mmol/L (3.5-5.4)

d) Chloride : 104 mmol/L (98-108)

4) X-ray – to detect any abnormalities in the patient's abdomen

Result:a) The abdomen is normal.

5) Blood and Cross Matching (GXM)- to know the patient's blood to blood tranfer done smoothly (if necessary)

Result:a) Blood group : Ob) Rhesus factor : positive

BAHAGIAN 7: PENGURUSAN

Patients in the ward accompanied by his wife at about 8:23 am from emergency departmant

Hospital Sultanah Bahiyah (refferal case from Hospital Jitra).

1. Patient was received, and registered in record books.

2. Patients are placed in the room as the patient condition is not severe

3. Vital signs such as body temperature, blood pressure and respiratory rate were

recorded

4. Patients was rest in bed and taking patient history as the main complaint, history

5. Patients undergoing general examination and physical examination (inspection,

percussion, palpation and auskultalsi)

6. Laboratory investigations were carried out as Full Blood Count (FBC), Blood Urea

Serum electrolyte (Buse), etc.

7. Provided health education to patients and patients waiting for surgery after getting a

diagnosis and was told by the nurse.

.Preparation and Care of Patients Before Surgery (Pre Operative Care)

1. Describes the surgical procedure "right hernioplasty" advantages and

complications derived from patients

2. Advising patients not to worry to face surgery

3. Obtain consent from the patient

4. Doing investigation Buse, Full Blood Count, and Diagnostic Imaging.

5. Blood and Gross do match to replace a lot of blood in case of bleeding

6. Starve the patient "Nil By Mouth" 6 hours before surgery

7. Intake of vital signs to ensure stable patients

8. Wearing surgical gowns and oil cap

9. Send the patient to the operating theater (Dewan bedah)

.

Patient Care After Surgery (Post Operative Care)

1. Receive patients from the operating theater

2. Consuming vital sign every 15 minutes, then every ½ hour and 2 hours to monitor

development as the first post-operative patients

3. 3 pint Infuse Normal Saline 0.9% intravenously to prevent dehydration

4. Observations on the surgery 2 times a day

5. Patients are allowed to eat by mouth after fully realized with a soft diet

6. Patients fully rest on the bed

 Treatment medications given

1. Patients are given medications such as:

Paracetamol TDS 1000mg for 5 days

. Action : acts as antipiratik and analgesics to patients.

Side effects : vomiting, nausea, abdominal pain.

Tramal capsules 50 mg TDS for 5 days

Action : This narcotic type drugs act to reduce the pain experienced by

patients after surgery.

Side effects : constipation, nausea, dizziness, vomiting and weak pulse.

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Patients require adequate rest to the healing of wounds due to surgery

2. Patients should not make any heavy work to prevent incidents recurring hernia

3. Patients are encouraged to wear tight underwear

4. Patients are advised to reduce smoking because smoking can result in a patient

suffering from a cough that also can contribute to the occurrence of this hernia.

5. Patients should keep diet by eating foods that are nutritious and high in protein to

promote wound healing, such as fish

6. Patients are not allowed to apply water to prevent infection of surgical wounds in the

vicinity

7. Make sure that every doctor's appointment with a good compliance.

8. Patients should avoid emotional stress to speed up the healing process

9. Advise the patient to take care of personal hygiene.

10. Do refer to hospital if there are complications

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:

Daripada ‘clerking case’ yang saya lakukan di wad kenanga 3C Hospital Sultanah

Bahiyah ini, banyak pembelajaran dan pengalaman baru yang saya perolehi. Antaranya ialah

saya berdepan dengan situasi sebenar pesakit yang betul dalam keadaan yang sakit dan

bagaimana cara untuk menangani situasi tersebut. Disamping itu, pesakit juga banyak

memberi kerjasama semasa mendapatkan riwayat pesakit, pengambilan sejarah dan

pemeriksaan fizikal. Saya juga dapat mengetahui lebih lanjut mengenai penyakit ingunial

hernia dan penyebabnya. Saya juga boleh melihat sendiri simtom-simtom yang dihadapi oleh

pesakit yang sebelum ini hanya mengetahui daripada teori semata-mata. Saya juga

berpeluang mempelajari dan mengendali pengurusan pra dan post-operative ini dalam

keadaan sebenar. Selain itu juga saya dapat mempraktikkan penjagaan kejururawatan yang

dipelajari di dalam kelas. Akhir sekali saya dapat mengetahui dan mengenali ubat-ubatan

digunakan dalam merawat kes yang berkaitan dengan penyakit ini seperti kaedah tindakan

ubat, dos, cara pemberian, interaksi ubat dan kesan sampingan ubat tersebut.

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