Institut Latihan Kementerian Kesihatan Malaysia: Nama Pelatih
Institut Latihan Kementerian Kesihatan Malaysia: Nama Pelatih
Institut Latihan Kementerian Kesihatan Malaysia: Nama Pelatih
CASE CLERKING
Nama:
Hospital/Klinik: Tarikh:
Aduan Utama:
O/E:
Sejarah Keluarga:
- married
- has a daughter
- other family unknown for comorbid
- No allergic history
Sejarah Sosial:
- Normal
- No tachycardia
- DRNM
2. Respiratory system
- Normal
- No tachypnic
- No dyspnea
- No wheezing/stridor
3. Circulatory system
- Normal
- No pale
- No cyanosis
4. Endocrine System
- Normal
- thyroid gland normal
- No lymph node enlargement
5. Exrectory system
- Normal
- kidney palpable
BAHAGIAN 3: PEMERIKSAAN FIZIKAL
Pemeriksaan Am:
Berat Badan:84kg
Jantung:
-inspection:
- Normal
- No scar
- No wound
- No barrel chest
- No deformiti
-palpation:
- No scar
- No bone fracture
-percussion:
- No scar
- No dullness sound
-Auscultation:
- DRNM
Paru-paru:
-inspection:
- normal
- normal expansion
-palpation:
- palpable
- no tenderness
-percussion:
- Normal
- Resonance
-Auscultation:
- normal
Abdomen:
- soft
- no tenderness
-inspection:
- Normal
- No scar
- No any skin disease
-palpation:
- Normal
- No scar
- Bowel sound normal
-percussion:
- Normal
- resonance
- no dullness
-Auscultation:
- Normal
Sistem Saraf:
Neurology
Right Left
Tone N N
Power At least 5/5 At least 5/5
Reflex N N
- No deformiti
- No clubbing fingers
- No varicose vein
- Positive all movement ( flexion , extension , abduction ,etc)
Lain-lain :
1)Genital
- Normal
- No tender
- No discharge
2) Rectum
- Congested
bilateral nasal
- Allergic Rhinitis
with Deviated
nasal septum
BAHAGIAN 5: DIAGNOSIS
Diagnosis
- Allergic Rhinitis with deviated nasal septum
Diagnosis Perbezaan:
- Sinusitis
- Nasal tumor
- Foreign body
- trauma
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 there is an increase or decrease in haemoglobin
2. Ambil tand vital pesakit: BP, pulse rate, temp, spo2, pain score
3. Lakukan penyiasatan:
a) Ujian Nose endoscopy
b) Ujian darah FBC
c) Nasopharyng swab for c&S
4. Medication:
a) Avamys nasal spray 2p OD x 2/12
b) Tab loratadine 10mg OD X 2/12
5. Surgery
a) Septoplasty to straighten bone and cartilage of nasal septum
6. Beri TCA 2/12 untuk melihat perkembangan dan komplikasi jika ada
Memuaskan
Lemah
Daripada clerking case yang saya lakukan di Klinik ENT, saya berpeluang mendapatkan pengalaman
dan pengetahuan yang lebih mendalam merangkumi pelbagai aspek. Kerjasama yang baik dari staf
kakitangan klinik sangat banyak membantu saya memahami sekaligus menyiapakan case clerking ini
dengan baik.