Case Clerking Hernia

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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 : MOHD EIZAIRIE BIN ABDUL MUTALIB : DBMA11-6071 : 910709-04-5023 :2/2 : WAD 3C (PEMBEDAHAN) HOSPITAL SULTANAH BAHIYAH , ALOR SETAR, KEDAH DARUL AMAN KURSUS DIPLOMA PEMBANTU PERUBATAN CASE CLERKING Nama Pelatih No. Matrik Tahun Kawasan Penempatan : MOHD EIZAIRIE BIN ABDUL MUTALIB : DBMA11-6071 : 2 Seme
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    KURSUS DIPLOMA PEMBANTU PERUBATANKOLEJ PEMBANTU PERUBATANALOR 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 , ALORSETAR, KEDAH DARUL AMAN  KURSUS DIPLOMA PEMBANTU PERUBATAN CASE CLERKING  Nama Pelatih: MOHD EIZAIRIE BIN ABDUL MUTALIBNo. Matrik: DBMA11-6071Tahun: 2 Semester: 2Kawasan Penempatan: HOSPITAL SULTANAH BAHIYAH BAHAGIAN 1: BUTIR-BUTIR PERIBADI PESAKIT Nombor Pendaftaran: AS 00330537Nombor K/P:-TIDAK PERLU-Nama:-TIDAK PERLU DIISI -Jantina: Lelaki/Perempuan* :LELAKIBangsa:MELAYUPekerjaan:JURUTEKNIK ALARMUmur:29 THN Alamat:-TIDAK PERLU-No. Tel:-TIDAK PERLU-Hospital/Klinik:HOSPITAL SULTANAH BAHIYAHTarikh: MASUK WAD:17-01-2013 @8.23 AMKELUAR 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 herniab)able to BO (bowel open) and pass flatusc)no vomiting d) swelling increase in size (5cm × 5 cm)e)otherwise no other symptomf)PU (pass urine) normal ; no dysuriag)No h/o traumah)No h/o insect bite to the affected area Sejarah Penyakit Lalu:(Termasuk alahan ubatan) a)No known allergy to food or any drugsb)Not taken any traditional drugs or treatmentc)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 diseasef)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 healthyc)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)Normalb)DRNM (dual rythm no murmur)c)S1S2 normal with regular rythmd)No chest pain while breathing 2.Respiratory system a)Normalb)Respiration rate – 22/minc)Pulse rate – 77/mind)No dyspnoea, no wheezinge)No stridor  3.Circulatory system a)Normalb)No palec)No cyanosed)No dizzinesse)No anaemia 4.Skeletal system a)Normalb)Positive motor reflexc)Brudzinski sign negative 5.Exrectory system a)Normalb)Bowel sound normalc)Kidney palpable 6.Musculoskeletal system a)Normalb)Muscle reflex positivec)No muscle dystrophyd)No tender or warm 7.Endocrine system a)Normalb)No thyroid gland enlargementc)No tremor 
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