INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA

ALOR SETAR (PEMBANTU PERUBATAN)

CASE CLERKING

MUHAMMAD HAZIQ DANIAL BIN KHARIRI

Nama Pelatih : ………………………...………………………………………
BPP2018-0050
No. Matrik : …………………………………………………….….……….

3 1
Tahun : ……….........… Semester : ………………………..
JABATAN KECEMASAN & TRAUMA
Kawasan Penempatan : ....………………………………………………..……………

BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT

Nombor Pendaftaran: Nombor K/P:

-TIDAK PERLU DIISI - -TIDAK PERLU DIISI -

Nama:

-TIDAK PERLU DIISI -

Jantina: Lelaki/ Bangsa: Pekerjaan: Umur:

Perempuan*

LELAKI INDIA POLIS 40 TAHUN

Alamat: No. Tel:

-TIDAK PERLU DIISI - -TIDAK PERLU

DIISI -

Hospital/Klinik: Tarikh:

JABATAN KECEMASAN & TRAUMA HOSPTAL SIK 25/6/2020

BAHAGIAN 2: RIWAYAT PESAKIT

Aduan Utama:

Difficulty in moving his left arm and leg

Sejarah Penyakit Kini:

- Brought to ED by his family after being unable to getout of bed this morning
around 6.30 a.m @ 25.06.2020

- His family noticed taht his face was drooping to left sided especially his left lip.

- currently pt :
+Numbness
+Speech slurred
+Headache and dizziness
+Unable to lift uphis left side upper and lower limb.
O denies any visual change,cognitive deficits and aphasia

- 2 years ago,he suffered similar symptom also left sided but recovery after 30
minutes.
- Diagnosis by Doctor as TIA was given aspirin at the moment.Now he under
Hypertension medication.He compliant with all medication

Sejarah Penyakit Lalu:

(Termasuk alahan ubatan)

- Known case of Hypertension,under ∆ and ↓ KK Jeniang and Hospital Sik

- Medication : T.Captopril 12.5 mg OD
T.Amlodipine 10mg OD
T.Hydrocholothiazide 12.5mg OD

- Denies any allergy of food or medication

Sejarah Keluarga:

65 y/o Died at 64 y/o

having Ca Breast
CAD

Patient Health Hx of Stroke

40 y/o 37y/o 35 y/o

Sejarah Sosial:
 - Denies any alcohol or drug use
- Previous smoking Hx 6-7 stick per/day quit about 21/2 ago after ∆ TIA
- Work as Policeman
- Living with family,having 4 child

Sejarah O&G:

- Not Associated
KAJIAN SEMULA SISTEM-SISTEM TUBUH BADAN:

Neck : - Supple
- No carotid bruits
- Full and symetric carotid pulse
- Jugular venous distension

Cardiovascular : Regular rate rhythm

- No murmur,rubs or gallops

GI : - No Hepatosplenomegaly

EXT : - No clubbing of finger

- Nosplinter haemorrhage

Coordination : - Difficulty on left with finger to nose and heel to shin

Gait : Unable to access

KHAS UNTUK PEDIATRIK:

Sejarah Kelahiran:

Sejarah Pemakanan:

Sejarah Tumbesaran:

IMUNISASI:

Jenis Imunisasi Tarikh Jenis Imunisasi Tarikh

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

Pemeriksaan Am: Well nourished elderly men
No apparent distress

Tanda Vital:

Penilaian kesakitan: 7 out of 10 pain scale

Suhu Badan: 37.9  ̊ C Kadar Pernafasan: 20/min TekananDarah:195/110

Kadar Nadi: 112 bpm Ritma Nadi: Regular Isipadu Nadi:

Berat Badan: 72kg Ujian Urin Glukosa: - Albumin: -

Pemeriksaan Kepala dan Sistem Deria Khas:

(termasuk Mulut, Tekak, Telinga, Hidung, Mata dan Leher)

Neck : Supple
- No carotid bruits
- No jugular venous distension
- Full ryhthm an symetric carotid pulse

Tongue : Protrude midline

Mouth : Lips slighty drop left side

Ears : Hearing Grossly intact

Eyes : Pupil equal and reactive to light

- Visual Acuity is 20/30 OU at near

Bahagian Dada:
Jantung:

+ Chest symetry movement

+ Regular rate,Dual ryhthm no murmurs
+ No rubs or gallops

Paru-paru:
+ Clear

+ Bilaterally air entry good

+ No SOB
Abdomen:

+ Soft

+ No tender

̊ + Bowel sound 7-11/min

Sistem Saraf: / Pemeriksaan Neurologikal

1 : Mental Status
+ Alert and oriented to self and situation
+ Speech is midly dysartic
+ No dysfluency of word

2 : Cranial Nerve
+ Pupil are equal and reactive to light
+ Funduscopic examination done and theres are no papilledema or retinal
haemorrhage
+Extra ocular movement are intact
+ Left facial weakness affecting the lower part of face
+ Good strength of sternocleidomastoid and trapezius bilaterally

3: Gait : Unable to access

Anggota Atas dan Bawah:

LEFT LEFT RIGHT RIGHT

UPPER LIMB LOWE UPPER LIMB LOWE
R LIMB R LIMB
POWER 3/5 3/5 5/5 5/5
REFLEX ¾ AT THE SAME 2/4 AT THE SAME
BICEP,TRICEP,KNEEAN BICEP,TRICEP,KNE
D ANKLE JERKS E AND ANKLE JERK
PLANTAR EXTENSOR ON THE FLEXOR ON THE
RESPOND LEFT RIGHT
E

Lain-lain:
(termasuk Genitalia, Rektum dan sebagainya)
BAHAGIAN 4: RINGKASAN PENEMUAN YANG PENTING DAN RELEVAN

BAHAGIAN 5: DIAGNOSIS

Diagnosis Sementara: Cerebral Vascular Accident with left hemiparesis

Diagnosis Perbezaan: Haemorrhagic stroke

Meningitis
Encephalitis
Atypical Migraine
Focal seizure

BAHAGIAN 6: PENYIASATAN DAN KEPUTUSAN YANG PENTING DAN

RELEVAN

1 : Cholestrol test : High in LDL 243 mg/Dl-might shown that are blockage in blood
supply
2 : Computered Tomography : Not very clear,as the incident occur within less 5
hour.Its work when then are blocakage in last 48-72 hour.MRI might be done.
3: PT/PTT : PT > 17 sec-to Access blood thinning medication avoiding haemorrhagis
stroke.
4: Blood Glucose : 5.7 mmol/L
5 :ESR : Done as suspected vasculitis.Result waiting
BAHAGIAN 7: PENGURUSAN

1. Patient was being rest and stabilize

2. After analyse the lab result thrombolytic theraphy done combine with
anticoagulant to get rid the blocakge
- Injection of tissue Plasminogen activator(TPA) Dipyridamole 20mg stat with
aspirin 150mg stat.
3. High Blood Pressure were monitored to avoid haemorrhagic stroke,if <130/80
o Tablet HCTZ 25mg
o Tablet Captopril 10mg
4. Suplement oxygen to prevent hipoxia as Spo2 96% using 3L nasal prong,
excessive oxygen may cause hyperventilation
5. To lowering cholestrol Tablet Lovastatin 25mg stat
6. Painkiller was given to relief pain.

BAHAGIAN 8: NASIHAT RELEVAN KEPADA PESAKIT/PENJAGA

1. Alert and aware with sign symptom of stroke

2. Control High blood pressure
- Exercising
- Managing stress
- Maintaining on healthy weight
3. Lower amount of cholestrol and saturated fats in your diet
4. Quitting smoking
5. Always compliant wth all medication prescribe
6. Follow all rehabilitation sesión
7. Let your family member what you want in term to recovery

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:

Based on this case clerking.Its shown that clinical syndrome which is stroke are not
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In good prognosis,as delay management may ruptured the blood vessel in the brain.
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Early management ,give this cases higher chance to recover as,the correct
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Investigation and treatment were completely done in the main goal to stabilize
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The patient condition and avoid any bleeding tendency.
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