Professional Documents
Culture Documents
Case Clerking MI
Case Clerking MI
Case Clerking MI
CASE CLERKING
Tahun :2 Semester :4
Nama:
Aduan Utama:
1. Chest pain over 1/7 last night
2. Headache for 1/52
3. Nause and vomiting
Sejarah Keluarga:
1. Live with his family at Senai
2. Has 3 children
3. His mother has myocardial infarction
Sejarah Sosial:
1. Activer smoker
2. No alcoholism
3. Work at factory as a supervisior
Sejarah O&G:
None
V) Musculosceletal system
- movement upper body and lower body normal
- patient was able to walk
Pemeriksaan Am:
Date :22.6.2021
I) Head
- no any cut or scar
-no swelling
II) Ear
-normal and patient can hear well
- no discharge or bleeding
- no swelling or pain
III) Eye
-normal
- no redness or jaundice
-no strabismus or cataract
IV) Nose
-normal and no scars or cuts
- no swelling or pain
V) Mouth
- normal and no scars or cuts
- odorless breathing
Bahagian Dada:
Jantung:
I)Inspection
-no scars
- no skeletal defect such as pigeon chest or barrel chest
II)Palpation
- no chest pain
- asymetrical chest movement
III)Auscultation
- no murmur
-apecs rhtym 97/min
Paru-paru:
I) Inspection
- no scars
- no abnormalities
II) Palpation
- no swelling
- normal chest movement
III)Percussion
-sounded ressonant
IV)Auscultation
-no crepitus
-no rhonci or stridor
Abdomen:
-No abdominal distension
-No color change
-No surgical scars
II)Palpation
-no pain or swelling
-soft
III)Percussion
-normal sound: resonans
IV)Auscultation
- normal bowel sound
Sistem Saraf:
-Positive reflex tendons
-Plantar positive reflex
-Positive biceps and triceps muscle movements when tested with hammer tendons
-Normal sensation i.e. the patient feels pain when pricked with a needle
Anggota Atas dan Bawah:
I)Pelvic
Inspection:
-no scar
Palpation
- no swelling or oedema
-no fracture
Anggota Atas
I)Inspection:
-no fractures
-no injuries
II)Palpation:
-no swelling
-can perform flexion, extension, circulation, abduction, adduction and rotation
normally
Anggota Bawah
I)Inspection
-no abnormalities
II)Palpation
-can perform flexion, extension, circulation, abduction, adduction and rotation
normally
Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
i.Genetelia
-Normal
-Normal urine excretion
-No discharge coming out of the patient's genitals
-No hematuria
ii.Rectum
-Normal
-Normal and regular bowel movements
-No bleeding and discharge coming out of the patient’s anus
-No melena stool
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN
BAHAGIAN 5: DIAGNOSIS
Diagnosis Perbezaan:
1.Angina Pectoris
2.Syncope
3. Congestive Cardiac Failure
4. Myocardial Infarction
5.Acute Myocardial Infarction
BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN
RELEVAN
Leucocyte : negative
Nitrate : negative
RBC : negative
Protein : negative
Ketone : negative
Bile : negative
3. Electro Cardiogram (ECG)
- ST Elevation
4. Glucometer
- Normal Range 6.8 mmol/L ( less than 140mg/dL 7.8 mmol/L)
5. Echocardiogram
- RV is infarcted, RV dilation, RV segmental wall motion abnormalities
BAHAGIAN 7: PENGURUSAN
4) Nursing Care
Memuaskan
Lemah
By doing a case study of this disease, I can see for myself the symptoms of this
disease and can find out about the investigation whether routine or specific. It can
equip us to perform IPPA procedures.Through the study of this disease, I was able
to learn about the handling in the surgical ward that is about the initial handling
during admission to the ward, the treatment given, medications and also nursing
care. It is more specific than what is obtained in lectures.
KURSUS DIPLOMA PEMBANTU PERUBATAN
JUMLAH 100
Nama : …………………………….………………
Tarikh : ……………………………………………
KURSUS DIPLOMA PEMBANTU PERUBATAN
PELAKSANAAN
Bil. Perkara Wajaran Memuas Skor Catatan
Baik Lemah
kan
Pembentangan
1 keterangan peribadi 1
pesakit yang tepat
Pembentangan riwayat 2
2
pesakit yang lengkap
Melakukan pemeriksaan
3
3 fizikal yang lengkap dan
relevan dengan betul
Pembentangan
1
4 diagnosis & diagnosis
perbezaan yang tepat
Cadangan penyiasatan
5 1
yang penting & relevan
Pembentangan
2
6 pengurusan pesakit yang
tepat dan lengkap
JUMLAH 10
Nama : …………………………….………………
Tarikh : ……………………………………………