KURSUS DIPLOMA PEMBANTU PERUBATAN CASE CLERKING
MUHAMMAD SHAFIK BIN SAAD : ………………………...……………………………………… BPP2009-12418 BPP2009-12418 : …………………………………………………….….……….
Nama Pelatih No. Mati!
$ah%&
Ka3a Ka3a'a 'a& & Pe&e Pe&em mat ata& a&
" # : ……….........… Seme'te : ……………………….. (ABA$AN (ABA$AN K)*)MASAN K )*)MASAN + $,AUMA HSPI$A H SPI$A SUN/AI SIPU$UP),AK : ....… ....……… ………… ………… ………… ………… ………… ………… ………… ………. …..… .……… ………… ……
BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT
Nom5o Pe&6a7taa&: ,& 24#"
Nom5o KP: -$IDAK P),U DIISI -
Nama: -$IDAK P),U DIISI (a&ti&a: ela!i Peem%a&
Ba&;'a:
)AKI Alamat:
INDIA
Pe!e
PIS
Um%:
40 $AHUN No. $el:
-$IDAK P),U DIISI -
-$IDAK P),U DIISI -
Ho'italKli&i!:
$ai!h:
(ABA$AN K)*)MASAN + $,AUMA HSPI$A SUN/AI SIPU$U P),AK.
2#82011
BAHAGIAN 2: RIWAYAT PESAKIT
A6%a& Utama: Di77i=%lt> i& mo?i&; hi' le7t am a&6 le;
Sea!it Ki&i:
-
Bo%;ht to )D 5> hi' 7amil> a7te 5ei&; %&a5le to ;eto%t o7 5e6 thi' mo&i&; ao%&6 ."0 a.m24.08.2011
-
Hi' 7amil> &oti=e6 taht hi' 7a=e 3a' 6ooi&; to le7t 'i6e6 e'e=iall> hi' le7t li.
-
=%e&tl> t : @N%m5&e'' @See=h 'l%e6 @Hea6a=he a&6 6ii&e'' @U&a5le to li7t %hi' le7t 'i6e %e a&6 lo3e lim5. 6e&ie' a&> ?i'%al =ha&;e=o;&iti?e 6e7i=it' a&6 aha'ia
- 2 >ea' a;ohe '%77ee6 'imila '>mtom al'o le7t 'i6e6 5%t e=o?e> a7te "0 mi&%te'. - 5> Do=to a' $IA 3a' ;i?e& a'ii& at the mome&t.No3 he C H>ete&'io& me6i=atio&.He =omlia&t 3ith all me6i=atio&
Sea!it al%: $ema'%! alaha& %5ata&
-
K&o3& =a'e o7 H>ete&'io&%&6e a&6 C KK S;.Si%t a&6 Ho'ital S;.Si%t. Me6i=atio& : $.*atoil 12.# m; D $.Amlo6ii&e 10m; D $.H>6o=holothiai6e 12.#m; D
-
De&ie' a&> alle;> o7 7oo6 o me6i=atio&
Seo ha?i&; *AD
Patie&t 40 >o
Die6 at 4 >o *a Bea't
Health "E>o
H o7 Sto!e "# >o
Se
-
De&ie' a&> al=ohol o 6%; %'e Pe?io%' 'mo!i&; H -E 'ti=! e6a> %it a5o%t 212 a;o a7te $IA Go! a' Poli=ema& i?i&; 3ith 7amil>ha?i&; 4 =hil6
Se
Not A''o=iate6
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:
Ne=! : - S%le - No =aoti6 5%it' - F%ll a&6 '>meti= =aoti6 %l'e - (%;%la ?e&o%' 6i'te&'io&
*a6io?a'=%la : ,e;%la ate h>thm - No m%m%%5' o ;allo' /I : - No Heato'le&ome;al> )$ : - No =l%55i&; o7 7i&;e - No'li&te haemoha;e
*oo6i&atio& : - Di77i=%lt> o& le7t 3ith 7i&;e to &o'e a&6 heel to 'hi& /ait : U&a5le to a==e''
KHAS UNTUK PEDIATRIK:
Se
Se
Se
IMUNISASI:
(e&i' Im%&i'a'i
$ai!h
(e&i' Im%&i'a'i
B*/
DP$ @ Polio Do' 1
Heatiti' B Do' 1
DP$ @ Polio Do' 2
Heatiti' B Do' 2
DP$ @ Polio Do' "
Heatiti' B Do' "
DP$ @ Polio Boo'te 1
*ama!
D$ @ Polio Boo'te 2
ai&-lai& im%&i'a'i
$ai!h
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
Pemei!'aa& Am: Gell &o%i'he6 el6el> me& No aae&t 6i'te'' $a&6a ital: Pe&ilaia& !e'a!ita&: E o%t o7 10 ai& '=ale S%h% Ba6a&: "E.9 J *
Ka6a Pe&a7a'a&: 20mi&
$e!a&a&Daah:19#110
Ka6a Na6i: 112 5m
,itma Na6i: ,e;%la
I'ia6% Na6i:
Beat Ba6a&: E2!;
U
Al5%mi&: -
Pemei!'aa& Keala 6a& Si'tem Deia Kha': tema'%! M%l%t $e!a! $eli&;a Hi6%&; Mata 6a& ehe Ne=! : S%le - No =aoti6 5%it' - No <%;%la ?e&o%' 6i'te&'io& - F%ll >hthm a& '>meti= =aoti6 %l'e $o&;%e : Pot%6e mi6li&e Mo%th : i' 'li;ht> 6o le7t 'i6e )a' : Heai&; /o''l> i&ta=t )>e' : P%il e%al a&6 ea=ti?e to li;ht - i'%al A=%it> i' 20"0 U at &ea
Baha;ia& Da6a: (a&t%&;: @ *he't '>met> mo?eme&t @ ,e;%la ateD%al >hthm &o m%m%' @ No %5' o ;allo'
Pa%-a%: @ *lea @ Bilateall> ai e&t> ;oo6
@ No SB
A56ome&: @ So7t @ No te&6e J
@ Bo3el 'o%&6 E-11mi&
Si'tem Saa7: Pemei!'aa& Ne%olo;i!al 1 : Me&tal Stat%' @ Alet a&6 oie&te6 to 'el7 a&6 'it%atio& @ See=h i' mi6l> 6>'ati= @ No 6>'7l%e&=> o7 3o6 2 : *a&ial Ne?e @ P%il ae e%al a&6 ea=ti?e to li;ht @ F%&6%'=oi= eami&atio& 6o&e a&6 thee' ae &o aille6ema o eti&al haemoha;e @)ta o=%la mo?eme&t ae i&ta=t @ e7t 7a=ial 3ea!&e'' a77e=ti&; the lo3e at o7 7a=e @ /oo6 'te&;th o7 'te&o=lei6oma'toi6 a&6 taei%' 5ilateall> ": /ait : U&a5le to a==e''
A&;;ota Ata' 6a& Ba3ah: )F$ UPP), IMB PG), ,)F)
"# A$ $H) BI*)P$,I*)PKN))AND ANK) (),KS PAN$A, )$)NS, N $H) ,)SPND) )F$
)F$ G), IMB "# SAM)
ai&-lai&: tema'%! /e&italia ,e!t%m 6a& 'e5a;ai&>a
,I/H$ UPP), IMB ## 24 A$ $H) BI*)P$,I*)PKN)) AND ANK) (),K F), N $H) ,I/H$
,I/H$ G), IMB ## SAM)
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN
BAHAGIAN 5: DIAGNOSIS
Dia;&o'i' Seme&taa:
*A 3ith le7t hemiae'i'
Dia;&o'i' Pe5eaa&:
Haemoha;i= 'to!e Me&i&;iti' )&=ehaliti' At>i=al Mi;ai&e Fo=al 'ei%e
BAHAGIAN :
PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN RELEVAN
1 : *hole'tol te't : Hi;h i& D 24" m;Dl-mi;ht 'ho3& that ae 5lo=!a;e i& 5loo6 '%l> 2 : *om%tee6 $omo;ah> : Not ?e> =leaa' the i&=i6e&t o==% 3ithi& le'' # ho%.It' 3o! 3he& the& ae 5lo=a!a;e i& la't 48-E2 ho%.M,I mi;ht 5e 6o&e. ": P$P$$ : P$ L 1E 'e=-to A==e'' 5loo6 thi&&i&; me6i=atio& a?oi6i&; haemoha;i' 'to!e. 4: Bloo6 /l%=o'e : #.E mmol # :)S, : Do&e a' '%'e=te6 ?a'=%liti'.,e'%lt 3aiti&;
BAHAGIAN !: PENGURUSAN
1. Patie&t 3a' 5ei&; e't a&6 'ta5ilie 2. A7te a&al>'e the la5 e'%lt thom5ol>ti= theah> 6o&e =om5i&e 3ith a&ti=oa;%la&t to ;et i6 the 5lo=a!;e - I&i6amole 20m; 'tat 3ith a'ii& 1#0m; 'tat. ". Hi;h Bloo6 Pe''%e 3ee mo&itoe6 to a?oi6 haemoha;i= 'to!e;oa li' 1"080 - $a5let H*$ 2#m; - $a5let *atoil 10m; 4. S%leme&t o>;e& to e?e&t hioia a' So2 9O %'i&; " &a'al o&;.e=e''i?e o>;e& ma> =a%'e h>e?e&tilatio& #. $o lo3ei&; =hole'tol $a5let o?a'tati& 2#m; 3ee 'tat . Pai&!ille 3a' ;i?e& to elie7 ai&.
BAHAGIAN ": NASIHAT RELEVAN KEPADA PESAKIT#PENJAGA
1.
2.
". 4. #. . E.
Alet a&6 a3ae 3ith 'i;& '>mtom o7 'to!e *o&tol Hi;h 5loo6 e''%e - )e=i'i&; - Ma&a;i&; 'te'' - Mai&tai&i&; o& health> 3ei;ht o3e amo%&t o7 =hole'tol a&6 'at%ate6 7at' i& >o% 6iet %itti&; 'mo!i&; Al3a>' =omlia&t 3th all me6i=atio& e'=i5e Follo3 all eha5ilitatio& 'e'iQ& et >o% 7amil> mem5e 3hat >o% 3a&t i& tem to e=o?e>
LAPORAN REFLEKTIF: Bei!a& !ome& me&;e&ai em5elaa&; telah 6ieolehi 6aia6a e&;!a
Pe&;%%'a& !e':
Bai!
Mem%a'!a&
emah
,e7le!'i em5elaa&; 6ieolehi 6aia6a e&;!a&6ome 3hi=h i' 'to!e ae &ot ....................................................................................................................................... I& ;oo6 o;&o'i'a' 6ela> ma&a;eme&t ma> %t%e6 the 5loo6 ?e''el i& the 5ai&. ....................................................................................................................................... )al> ma&a;eme&t ;i?e thi' =a'e' hi;he =ha&=e to e=o?e a'the =oe=t ....................................................................................................................................... I&?e'ti;atio& a&6 teatme&t 3ee =omletel> 6o&e i& the mai& ;oal to 'ta5ilie ...................................................................................................................................... $he atie&t =o&6itio& a&6 a?oi6 a&> 5lee6i&; te&6e&=>. ....................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
KURSUS DIPLOMA PEMBANTU PERUBATAN FORMAT PEMARKAHAN CASE CLERKING MUHAMMAD SHAFIK BIN SAAD BPP2009-12418 N$%$ P&'$()*: ++++++++++++++++ N, M$(.)/: +++++++ 3 5 A0E HOSPITAL SG T$*: ++ S&%&(&.: +++ K$$$ P&&%$($: ++++++++++ SIPUT6U78PERAK B)' P&./$.$ W$9$.$ S/,. $($($ 1 Ketea&;a& Pei5a6i Pe'a!it 5 2 R)$;$( P&$/)(: 2.1A6%a& Utama 2.2Sea!it Ki&i 2."Sea!it al% 25 2.4Sea&; 5e!e&aa& " P&%&.)/$$ F)<)/$': ".1Pemei!'aa& Am ".2 $a&6a-ta&6a ital "."Keala + ))N$ ".4Da6a (a&t%&; ".#Da6a Pa%-a% 25 ".A56ome& ".ESi'tem Saa7 ".8 A&;;ota Ata' + Ba3ah ".9ai&-lai& 'eeti ;e&italia + e!t%m 6ll Ma&a2 >a&; 5e!e&aa& 4 ,i&;!a'a& Pe&em%a& Kli&i!al 5 # D)$=,): #.1 Dia;&o'i' Seme&taa 5 #.2 Dia;&o'i' Pe5eaa&
E
8 9
Pe&>ia'ata& Ra&; Pe&ti&; + ,ele?a& P&=.$: E.1 Pe&;e&6alia& a3al E.2 U5at-%5ata& E." Pe&
5 2> 5 5 1>>
$a&6ata&;a& Pemei!'a
: ……………………………….……………
Nama
: …………………………….………………
$ai!h
: ……………………………………………
KURSUS DIPLOMA PEMBANTU PERUBATAN SENARAI SEMAK CASE PRESENTATION N$%$ P&'$()*: ++++++++++++++++
N, M$(.)/: +++++++
T$*: ++ S&%&(&.: +++ K$$$ P&&%$($: +++++++++ B)'
P&./$.$
W$9$.$
1
Pem5e&ta&;a& !etea&;a& ei5a6i e'a!it >a&; teat
2
Pem5e&ta&;a& i3a>at e'a!it >a&; le&;!a
"
4
1
Mela!%!a& emei!'aa& 7ii!al >a&; le&;!a 6a& ele?a& 6e&;a& 5et%l Pem5e&ta&;a& 6ia;&o'i' + 6ia;&o'i' e5eaa& >a&; teat
#
*a6a&;a& e&>ia'ata& >a&; e&ti&; + ele?a&
Pem5e&ta&;a& e&;%%'a& e'a!it >a&; teat 6a& le&;!a JUMLAH
PELAKSANAAN M&%$ B$)/ L&%$* /$
2
"
1
1 2
1>
S/,.: +++ ? 1>>@ @ 1>
$a&6ata&;a& Pemei!'a
: ……………………………….……………
Nama
: …………………………….………………
$ai!h
: ……………………………………………
S/,.
$($($
