KURSUS DIPLOMA PEMBANTU PERUBATAN KOLEJ 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
Kawasan Penempatan
: HOSPITAL SULTANAH BAHIYAH
Semester
: 2
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:
No. Tel:
-TIDAK PERLU-
-TIDAK PERLU-
Hospital/Klinik: HOSPITAL SULTANAH BAHIYAH
Tarikh: MASUK WAD: 17-01-2013 @ 8.23 AM KELUAR 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 system a) Normal b) DRNM (dual rythm no murmur) c) S1S2 normal with regular rythm d) No chest pain while breathing 2. Respiratory system a) Normal b) Respiration rate – 22/min c) Pulse rate – 77/min d) No dyspnoea, no wheezing e) No stridor 3. Circulatory system a) Normal b) No pale c) No cyanose d) No dizziness e) No anaemia 4. Skeletal system a) Normal b) Positive motor reflex c) Brudzinski sign negative 5. Exrectory system a) Normal b) Bowel sound normal c) Kidney palpable 6. Musculoskeletal system a) Normal b) Muscle reflex positive c) No muscle dystrophy d) No tender or warm 7. Endocrine system a) Normal b) No thyroid gland enlargement c) No tremor
KHAS UNTUK PEDIATRIK: Sejarah Kelahiran: Sejarah Pemakanan: Sejarah Tumbesaran: IMUNISASI: Jenis Imunisasi
Tarikh
Jenis Imunisasi
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
Tarikh
3. Pemeriksaan Kepala dan Sistem Deria Khas: (termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher) a) Head i) Inspection -normal -no tumor -no moon face -no external skull b) Ears i) Inspection -normal -clean ; no discharge -no bleeding -no scar c) Nose i) Inspection -normal -clean -no discharge d) Eyes i) 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) Mouth i) Inspection -normal -pink -not pale -hydration fair -no ulcer ; no bleeding f) Neck i) Inspection -normal -jugular vein normal ii) Palpation -no thyroid gland enlargement -no trachea deviation
Bahagian Dada: Jantung: clear
1) Inspection a) Normal b) No scar c) No wound/bleeding d) No barrel chest e) No deformiti 2) Palpation a) Normal b) No bone fracture c) Apex beat normal 3) Percussion a) Normal b) No dullness sound c) Resonance 4) Auscultation a) Normal b) No gallop sound c) S1S2 normal d) DRNM (dual rythm no murmur)
Paru-paru: Lung clear
1) Palpation a) Normal b) Symetrical while breathing 2) Percussion a) Normal b) Resonance
3) Auscultation a) Normal b) No rhonki c) No wheezing d) No crepitus e) Air entry equal bilateral
Abdomen:
Clear
1) Inspection a) Normal b) No scar c) No any skin disease 2) Palpation a) Normal b) No scar c) Bowel sound normal 3) Percussion a) Normal b) Dullness 4) Auscultation a) Normal b) Bowel sound heared
Sistem Saraf: 1) 2) 3) 4) 5)
Positive tendon reflex Positive plantar reflex Sensory function Superficial touch normal Pain when prick
Anggota Atas dan Bawah: 1) 2) 3) 4) 5)
No deformiti No clubing fingers No varicose vein Positive all movement (flexion, extension,abduction etc) Hand dominance : right
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) Genital a) Swelling 5cm × 5cm at right inguinal region, extending to scrotum b) Tender c) Not reducible
2) Rectum a) Normal b) No per rectum mass c) No discharge d) No rectum prolapse e) No hemorrhoid
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN
Scrotum is growing and tender
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. Spermatocele
BAHAGIAN 6:
PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN 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) b) c) d)
WBC (White blood cell) RBC (Red blood cell) Hb (Haemoglobin) Platelet
: 9.07×10^3 µL (5.2 – 12.4.) : 493×10^6 µL (4.50-5.50) : 14.3 g/dL (13.0 -17.0) : 271 x 10^3/uL (150-410)
3) RP ( Renal profile) - detect any abnormalities of renal function and to know the electrolyte balance in the body of the patient.
Result: a) Creatinine urea b) Sodium c) Potassium
: 75 µmol/L : 139 mmol/L (133-145) : 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 : O b) 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.
