PROGRAM PEMBANTU PERUBATAN

CASE CLERKING

Nama Pelatih : Francis Jalong

No.matrik : BPP2017-3494

Tahun : 3 SEMESTER 1

Kawasan Penempatan : Hospital Sri Aman ( Unit Kecemasan & Trauma )

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

No.pendaftaran: MADAM X Nombor K/ P:

-TIDAK PERLU DIISI-
Nama: -TIDAK PERLU DIISI-

Jantina: Perempuan Bangsa: Pekerjaan: Umur:42

Melanau Surirumah tangga

Alamat: No.Tel:
-TIDAK PERLU DIISI- -TIDAK PERLU DIISI-

Klinik: Hospital Sri Aman ( Unit Kecemasan & Trauma ) Tarikh:21/8/2019

BAHAGIAN 2 : RIWAYAT PESAKIT

Aduan Utama:

C/O : vomiting fresh blood mix with blackish blood since 3/7

Sejarah Penyakit Kini:

- Reduce oral intake for 3 days

- Otherwise, having fever
- Claimed having a chest pain
- Patient complaint having a dizziness and due to dizziness she feel always want
to fall herself
- Complaint about having blackish stool if BO

Sejarah Penyakit Lalu:

(termasuk alahan ubat-ubatan)
u/c Gastric malignancy ( refused intervention )
- Consulted multiple times for OGDS but patient still refused
- Ovarian lesion T4N2M1
- Bilateral mild hyrdronephrosis
- Mist NaCl 15 ml tds for 1/52
- Mist UCL 15 ml tds for 1/52
- Syirup MMT 15 ml tds for 1/52
- Tablet Pantoprazole 40 mg OD for 2/52
- Tablet Vitamin B Complex 1/1 OD for 2/52
- Tablet ferrous Fumerate 2 tablet OD for 2/52
- Tablet folic Acid 1/1 OD for 2/52

Sejarah keluarga:
- Patient was elder daughter from 5 siblings
- Both patient parent have passed away
- Patient claimed 2 of her siblings have diabetes and hipertension
Sejarah sosial:
- Patient non smoker
- Patient even non an occasional drinker
- She have married and have two children
- She are just an housewife
KAJIAN SEMULA SISTEM – SISTEM TUBUH BADAN
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
Pemeriksaan Am:
Tanda Vital:

 Suhu Badan :37.1 º C

 Kadar pernafasan : 24
 Tekanan darah : 91/63
 Kadar nadi : 146
 Ritma nadi : Regular
 Isipadu nadi : Present ( strong pulse volume )
 Berat badan : 52.4 kg
 Ujian Urin Glukosa : 7.6 mmol/L
 Ujian Urin Albumin : Negative

Pemeriksaan Kepala dan Sistem Deria Khas:

(Termasuk Telinga, Hidung, Mata, Leher)

 Kepala : no surgery scar, no open or closed wound, no bleeding, no

swelling, no tenderness, patient having alopecia

 Telinga : no discharge, no surgery scar, size and shape equal for both ear

 Mata : no vision problems, no blur vision, no retina bleeding detected,

no abnormality of conjunctiva, pupil and sclera, no swelling around eyes lid

 Leher : no surgery scar detected, no swelling around neck, no

tenderness and normal jagular vein

 Tekak dan mulut : no swelling of throat, no redness, normal uvula, no

redness or enlargement of tonsil, dry lips and tounge. no ulcer, no redness
around mout
  Muka : no scar surgery, no racoon eyes, no face swelling, both side of

face equal

 Hidung : no discharge, no bleeding, no nasal polyps, no rhinorrhea, no

foreign body

Sistem Pernafasan:
 Inspeksi : no scar surgery, no hematoma, symmetrical chest movement,
no pectus excavatum and pectus carinatum
 Palpasi : no swelling of chest, no mass detected
 Auskultasi : equal air entry for both of lung, no ronchi, no crept and no
transmitted sound
 Perkusi : resonance sound, no hyper resonance, no dullness sound

Sistem Kardiovaskular:
 Inspeksi : no surgery scar, no hematoma, no pectusexcavatum and pectus
carinatum
 Palpasi : no tenderness, apex can be palpate, no removement of heart
from it origin side ( left side chest intercostal space five and mid clavicular line)
 Auskultasi : dual rhythm no murmur (DRNM), S1,S2 present

Sistem alimentari:
 Inspeksi : no surgery scar, no swelling, no ascites, no redness, no allergic
reaction detected
 Auskultasi : normal peristalsis sound ( 5-6 sound per minute )
 Perkusi : no dullness
 Palpasi : no tenderness, no distension of abdomen, soft
Sistem saraf:
 Reflex:
Reflex Kanan Kiri

Reflex pupil ↑↑

Plantar reflex ↑↑ ↑↑

Knee jerk ↑↑ ↑↑

Triseps reflex ↑↑ ↑↑

↑↑ (tindak balas normal)

Sistem Muskuloskeletal:
 Anggota atas:
Inspeksi : no clubbing of finger, no swelling, no surgery scar, no
hematoma, no tremor
Palpasi : no deformity, no edema, no tenderness
Sirkulasi : capillary refill time less than 2 second ( < 2 second ), radial
artery and brachial artery palpateable, same rhythm of pulse for both hand
 Anggota bawah:
Inspeksi : no surgery scar, no swelling, no hematoma, no pedal edema
Palpasi : no tenderness, no edema, no deformity,
Sirkulasi : pulse on dorsalis pedis, posterior tibia and poptelial palpateable

Anggota Atas dan Bawah Nilai Catatan

Bahu 5/5 Normal
Siku 5/5 Normal
Pergelangan tangan 5/5 Normal
Lutut 5/5 Normal
Pergelangan kaki 5/5 Normal
Lain-lain:
(Termasuk Genitalia, Rektum dan sebagainya)
- No swelling on patient genitalia
- No tenderness on genitalia
Per Rectum ( PR ) : Supervised and reviewed by Medical Officer
- Malenia stool present
 BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

Pale

-Poor hydration
Lung clear

-no ronchi

Dual Ryhtm No Murmur -no crepitation

-S1,S2 present -equal air entry

both lung
Abdominal

-Soft no tenderness

No pedal edema for both

leg

Capillary refill time,CRT less than 2 seconds ( < 2 seconds )

Per Rectum , PR ( malenia stool present )

BAHAGIAN 5: DIAGNOSIS

Diagnosis Sementara :
Upper Gastrointestinal Bleeding 2° Bleeding Gastric Mass

Diagnosis Pembezaan :
- Gastritis
- Peptic Ulcer
- Gastro Duodenal Erosion
- Gastroesophageal Varices
- Boerhaave Syndrome ( spontaneous esophageal perforation )
- Lower gastrointestinal bleeding
BAHAGIAN 6: PENYIASATAN YANG PENTING DAN RELEVAN
A) Full Blood Count
To determine amount of red and white blood cell then relate to rate of infection,
amount of haemoglobin and platelet
Date Taken : 21/8/2019
Test Result Reference Range Finding

White Blood Cell 10.6 uL 4.0-11.0 uL Normal

(WBC)
Red Blood Cell 3.8 uL 4.7-6.1 uL Low
(RBC)
Haemoglobin 8.7 g/dL 14.1-18.1 g/dL Low

Platelet 742 uL 130.0 – 400.0 uL High

B) Renal Profile
To determine electrolyte in blood stream and detect abnormality due to renal
function
Date Taken : 21/8/2019
Test Result Reference Range Finding

Na 116 mmol/L 134-145 mmol/L Low

K 3.3 mmol/L 3.5-5.0 mmol/L Low

CI 85 mmol/L 95-108 mmol/L Low

UREA 4.1 mmol/L 1.7-8.3 mmol/L Normal

CREA-D 29 u mol/L 45-90 u mol/L Low

C) Coagulation Profile (COAG)
To measure time taken for blood to coagulate
Date Taken : 21/8/2019
Test Result Reference Range Finding

Prothrombin Time 9.7 secs 11-16 secs High

(PT)
Partial 23.8 secs 30-40 secs High
Thromboplastin
(PTT)
International 0.81 secs 2-3 secs Low
Normalized Ratio
(INR)

D) Urine Full Examination Microscopic Examination (UFEME)

To detect sign of infection and abnormality in urine sample
LABSTIX RESULT

pH 4.8

Glucose 2+

Ketone 1+

Leucocytes Negative

Nitrite Negative

Protein Negative

Erythrocyte Negative
 MICROSCOPIC RESULT

Pus Cell 2-5 phpF

Red Blood Cell NIL

Epithelial Cell NIL

Cast Granular cast 1+ seen

Crystal NIL

Others NIL

E) Electrocardiogram (ECG)
To detect abnormal rhythm and electrical conduction of heart
Date Taken : 21/8/2019
Rate 125

Rhythm Sinus Tachycardia

P Wave 0.10 secs

PR Interval 0.20 secs

QRS Complex 0.08 secs

Finding : Normal Sinus Tachycardia

BAHAGIAN 7: PENGURUSAN
Management at Klinik Kesihatan
- Received and register patient
- Calm down the patient
- Give patient comfortable position to reduce pain
- Vital sign take: blood pressure, temperature, pulse, respiration rate, hypocount,
oxygen rate (spo2) and Pain Score
- History taking from patient and closed relative that know the story
- Electrocardiogram examination
- Set IV line and give drip IV Normal Saline 0.9% 1 pint run slow bolus
- Record all the finding and medication given in referral letter
- Handing over case to Medical Officer incharge to review before refer the patient
to nearest Emergency and Trauma Unit/Department

Management at Emergency and Trauma Unit/Department

- Received and register patient

- Triage the patient according to severity of the case
- Place the patient at red zone
- Make sure surrounding are safe for continue any procedure or treatment
- Ask patient to rest in bed and calm down the patient
- Vital sign taken : blood pressure, temperature, pulse, respiration rate,
hypocount, oxygen rate (spo2) and Pain Score
- Carry on physical examination from head to toe
1) Primary Survey
- DRABCDE Examination
- Danger : Keep surrounding safe
- Response : Determine response of the patient either conscious or not
- Airway : Clear the patient airway to prevent respiratory distress
Use head tilt chin lift or jaw thrust method to examine patient airway and
remove or suck any object that block patient airway
- Breathing : Examine breathing patern of patient
Inspection : examine any surgery scar or abnormal breathing
Auscultate : Determine air entry in both lung of the patient
Percussion : To detect dullness or hyper resonance sound in patient lung
 Palpation : Palpate patient chest to detect unsymmetrical movement of chest or
position of trachea
- Circulation : Examine the blood circulation of the patient
Determine the pulse rate and rhythm of the pulse and capillary refill time of the
patient.
Set IV line for blood taking, blood transfusion if needed and to maintain
electrolytes in patient body
Use Cardiac Monitor or Pulse Oximetry to observe the circulation of patient
- Disability : To determine the consciousness of the patient
Examine the Glasgow Coma Scale (GCS) of the patient
Eye : 4 Verbal : 5 Motor : 6 Total : 15/15
- Alert : Patient fully conscious arrived Red Zone
- Verbal : Patient can communicate normally and answer when get asked by
medical officer
- Pain : Patient conscious and doesn’t need any stimulation such as finger
squeezing
- Unresponsive : Patient can respond normally to any situation
- Exposure : Examine to detect sign of any life threatening symptom
ATOMFC : Airway obstruction, Tension pneumothorax, Open pneumothorax,
Massive haemothorax, Flail chest,and Cardiactemponade
- Work in team and get others staff for help
- Carry out ECG
- Set IV line 18G at both hand
- One hand for IV Normal Saline 0.9% and another hand for medication or ready
for blood transfusion
- Medication
IV Pantoprazole 40 mg stat to reduce production of gaster juice
IV Pantoprazole 80 mg run in infusion pump 4ml/hour
IV Maxolon 10 mg stat to overcome effect of Pantoprazole which is nausea
 2) Secondary Survey
- Examine the condition of the patient from head to toe
- Observe vital sign
- Obtain history from patient and closed relative for further medication
- Ask patient if having any history of allergic reaction to any drug or food
- Read history of medication given or medical illness of the patient before on Out
Patient Department Card
- Insert Chateter Bladder Drainage (CBD). Ask help from female staff .
- Analyzed results of blood sample and radiology examination ( x-ray) if any
- Stabilized the patient before admit to ward.

Management at ward

- Received and register patient

- Give comfort position to the patient
- Orientate the patient with ward rule and change patient shirt into ward attire
- Observing vital sign of the patient
- IV Normal Saline 0.9% 3 pint in 24 hours to stabilized the electrolytes in
bloodstream
- Input and Output Chart Observation taken
- Medication given with Medical Officer order
- Infusion of Pantoprazole 8 mg reduce secretion of gaster juice
- Blood taking for observation of FBC,RP
- Carry out ECG to observe heart rhythm
- Pre operation care
Ask the patient to fasting with in 8-10 hours before procedure.
Explain the procedure to patient and the relative.
Carry out soft diet plan for patient.
Hygiene care for patient.
- Ready for endoscopy
BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

ADMISSION IN WARD

- Explain rule in the ward and ask them to follow the rule
- Follow order from medical officer and staff nurse
- Advice patient about hygiene care
- Advice patient to alert any staff if any others complication occur as soon as
possible
- Take medication according to medical officer order
- Encourage oral intake and soft diet plan
- Ask patient to complete rest in bed for faster recovery

DISCHARGE FROM WARD

- Ask patient to take a good care and hygiene at home

- Advice the relative to continue observing the patient at home
- Explain and ask patient go to nearest clinic if having any health problem
- Continue taking the medication according to medical officerorder (if any )
- Advice patient to come for follow up for any dressing, or health review from
medical officer
- Ask patient to eat soft diet and avoid alcohol intake or spicy food
- During Bowel Open (BO) ask patient not to forcing her BO
LAPORAN REFLEKTIF

(Berikan Komen mengenai pembelajaran yang telah diperolehi daripada pengkajian kes
ini dan Pengurusan Kes ini)

Pengurusan Kes: Baik

Memuaskan

Lemah

Refleksi pembelajaran yang diperolehi daripada pengkajian kes ini:

Based on this case, I get a lot of information and knowledge of emergency treatment
plan for Upper Gastrointestinal Bleeding 2° Bleeding Gastric Mass. I have learned a lot
about sign and symptom or actual condition of patient that having this kind of disease
and how to proof the diagnosis through Lab Test such as Full Blood Count (FBC),
Renal Profile (RP) and more others. At the same time, I got to know about a lot
medication that use to treat this case.

Upper Gastrointestinal Bleeding (UGIB) was a bleeding that occur along upper
gastrointestinal for example present of blood at easophagus, gaster and duodenum.
Blood can be seen seen if the patient vomit or in condition of stool known as malenia
stool. Symptom UGIB depends on volume of blood loss and it also can cause
hypovolemic shock.

UGIB can be categorized according to anatomy condition and pathophysiology

factor such as ulcerative, vascular, traumatic, iatrogenic tumors and even a portal
hypertension. Continuous intake of Aspirin and Non-Steroidal Anti-Inflammatory
Drugs (NSAID) also can cause ulcer of peptic. This condition occur due to
inflammation of gaster mucosa surface and duodenum. Undetected ulcer can become
more worst and affect gastroduodenal and cause the artery wall weakening and
perforated. Then, the perforated artery cause UGIB.

Before I end this case, I want to acknowledge my Local Preceptor Mr. Alik, my
mentor Mr. Sylvester Thompson and all staff of ETU with a lot of thanks for helping
us during attachment at ETU Hospital Sri Aman. Thank you.
 KURSUS DIPLOMA PEMBANTU PERUBATAN

FORMAT PEMARKAHAN CASE CLERKING

Nama Pelatih: Francis Jalong No. Matrik: BPP2017-3494

Tahun:3 Semester:1 Kawasan Penempatan: Hospital Sri Aman

Bil. Perkara Wajaran Skor Catatan

1 Keterangan Peribadi Pesakit 5

2 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)

3 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)

4 Ringkasan Penemuan Klinikal 5

5 Diagnosis:

5.1 Diagnosis Sementara

5
5.2 Diagnosis Perbezaan

6 Penyiasatan Yang Penting & Relevan 5

 7 Pengurusan:

7.1 Pengendalian awal

20
7.2 Ubat-ubatan

7.3 Penjagaan kejururawatan

8 Pendidikan Kesihatan 5

9 Laporan reflektif 5

JUMLAH 100

Tandatangan Pemeriksa : ……………………………….……………

Nama : …………………………….………………

Tarikh : ……………………………………………
 KURSUS DIPLOMA PEMBANTU PERUBATAN

SENARAI SEMAK CASE PRESENTATION

Nama Pelatih: ………………………………………… No. Matrik: ………….…..…….

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

PELAKSANAAN
Bil. Perkara Wajaran Skor Catatan
Memuas
Baik Lemah
kan

Pembentangan keterangan
1 1
peribadi pesakit yang tepat

Pembentangan riwayat 2
2
pesakit yang lengkap

Melakukan pemeriksaan 3
3 fizikal yang lengkap dan
relevan dengan betul

Pembentangan diagnosis & 1

4 diagnosis perbezaan yang
tepat

Cadangan penyiasatan
5 1
yang penting & relevan

Pembentangan 2
6 pengurusan pesakit yang
tepat dan lengkap

JUMLAH 10
Skor: …….........… x 100% = ..........................%

10

Tandatangan Pemeriksa : ……………………………….……………

Nama : …………………………….………………

Tarikh : ……………………………………………