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KURSUS DIPLOMA PEMBANTU PERUBATAN KOLEJ PEMBANTU PERUBATAN ALOR SETAR CASE CLERKING TAJUK : RIGHT INGUINAL HERNIA NAMA PELATIH NO. MATRIK NO. KAD PENGENALAN TAHUN / SEMESTER KAWASAN PENEMPATAN :...
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BAHAGIAN 1 :BUTIR – BUTIR PERIBADI DAN PENGENALAN DIRI
Nomborpendaftaran:
Nombor K/P:
Nama :
Jantina : Lelaki / Perempuan *
Bangsa :
Pekerjaan :
Umur :
Alamat :
Wad / Klinik :
TarikhMasuk :
TarikhKeluar :
PengesahanKetuaJururawat/ StafKlinikalmengenaikesahihanbutir-butir yang tersebut di atas.
Betul / TidakBetul * Tandatangan :………………………….
Nama :
Tarikh : Cop Rasmi :
BAHAGIAN 2 :Butir-butirPeribadiPelatihdanPengkajianKes
TandatanganPengajar : ………………………………………..
NamaPengajar :
Tarikh : Cop Rasmi :
KOLEJ SAINS KESIHATAN BERSEKUTU KOTA KINABALU, SABAH
KURSUS DIPLOMA PEMBANTU PERUBATAN
CASE CLERKING
EAR, NOSE & THROAT (ENT) CLINIC
MAGS 3212
______________________________________________________________________________
ASSIGNMENT INDIVIDU
TAHUN 3 SEMESTER 2
LEFT EAR FOREIGN BODY
ELVICKER EMIN
BPP 2010 - 3336
PART 1 PATIENT'S HISTORY
(Chief Complain)
Foreign body leftleft ear since last night.
(History of Present Illness)
Alleged insect entrance on left ear last night.
Patient come to Emergency Department but only part of the insect had pulled out.
Refer to ENT clinic for further treatment.
No ear discharge.
Mild ear pain.
No tinnitus.
(Past Medical and Surgical History)
No past medical and surgical history.
No history of any allergies towards medication.
(Family History)
NIL.
(Social History)
Patient is a housewife.
Live with her family.
PART 2 PHYSICAL EXAMINATION
(General)
Patient pink, alert and stable.
Not tachypneic or respiratory distress.
No pallor, active and walk-in patient.
Communicate well and fully conscious.
Glasgow Coma Scale : 15/15.
Vital signs on arrival :
Blood Pressure : 130/70 mmHg
Pulse Rate : 80/minute
Respiratory Rate : 22/minute
SpO2 : 99%
Temperature : 37.1 ° C
(Physical)
Head and ENT System
Right ear:
Normal.
Tympanic membrane intact.
Left ear:
Part of insect in-situ.
Tympanic membrane intact.
No bleeding.
No redness, no discharge.
(Respiratory System)
Equal air entry of both lungs.
(Cardiovascular System)
No surgical scar.
Dual rhythm no murmur.
(Abdomen)
No surgical scar.
Soft.
No tender.
No abdomen distension.
Positive bowel sound.
(Central Nervous System)
Grossly intact.
No abnormality detected.
(Genitalia)
Not related.
(Pelvic)
Inspection : No abnormality noted.
Palpation : No abnormality noted.
(Upper Extremities – Right & Left)
No deformity or abnormality seen.
Able to move both hands without restrictions.
(Lower Extremities – Right & Left)
No deformity or abnormality seen.
Able to move both legs without restrictions.
PART 3 SUMMARIES AND RELEVANT IMPORTANT FINDING
General Condition: Alert, pink and stable.
GCS: 15/15
ENTRight ear: normal, tympanic membrane intactLeft ear: part of insect in-situ, tympanic membrane intact, no bleeding, no dischargeEYES -no hematoma-Pink-both pupil equel & react to lightRESPIRATORY- clear -equal air entry
ENT
Right ear: normal, tympanic membrane intact
Left ear: part of insect in-situ, tympanic membrane intact, no bleeding, no discharge
EYES
-no hematoma
-Pink
-both pupil equel & react to light
Dorsalis pedis artry palpable
Dorsalis pedis artry palpable
PART 4 DIAGNOSIS
Diagnosis
Foreign Body at Left Ear.
PART 5 INVESTIGATION AND RESULT
1.Otoscopy:
Right ear and left ear has undergo the otoscopy test and there was a foreign body found in the left ear.
2.Examination Under Microscope :
Both ear tympanic membrane intact, no bleeding, no discharge and no abnormality detected.
PART 6 MANAGEMENT
1.Accept patient
2.Otoscopy done.
Part of insect still in the left ear
3.Examination Under Microscope done.
Tympanic membrane intact.
Insect successfully sucked out.
4.Medication plan
Ofloxacin Ear Drops.
Cap Mefenamic Acid 500 mg PRN
PART 7 RELEVAN ADVICE TO PATIENT
Patient was adviced to take care of her ear cleanliness
Patient adviced to use the medication given as ordered
Patient was told not to dig up her left ear
Patient was adviced to take balanced diet
Patient has to come for the next follow up as given
Patient was adviced to come immediately to ENT clinic if there is some abnormilty appear.
PART 8 REFLECTIVE REPORT
Case Management :Good ( / )
Satisfying ( )
Weak ( )
Study reflection learned from case study :
Through this case, I had learn and knewa lot more about the management in Otolaryngology Specialist Clinic. This case is important to help me in giving an early management and treatment to patient effectively especially when I being posted either in Emergency Department or Klinik Kesihatan later. As a matter of fact, a case like this is surely need an urgent treatment and proper management to prevent from worsening.
Therefore, it's very important to know first the sign and symptom for this case to make easy the diagnosis and finally get refer this case to specific Department as well to ENT Clinic.
