STUDENT NAME SITI HALIJAH BINTI AZMAN
ID MATRIC DMA 2011-3177
SUBJECT COMMUNITY HEALTH
PLACEMENT I
CODE SUBJECT MPCH 2042
TOPIC BRONCHIAL ASTHMA
SUBMITTED DATE 13/1/2023
CASE CLEARKING 1
YEAR 2
SEMESTER 4
BATCH 16
DEPARTMENT EMERGENCY DEPARTMENT
PLACEMENT KLINIK KESIHATAN PUCHONG
CLINICAL INSTRUCTOR: SIR NADARAJAH
DIP MA CUCMS – Clinical Placement [1]
CLINICAL CASE CLERKING AND GENERAL MANAGEMANT FORM
Patient Gender : Male ( / ) Female ( ) R/N: 145083
Patient Race : Malay ( / ) Chinese ( ) Indian ( ) Others ( ) Age : 60 Y/O
Date / Time: 12 JANUARY 2023 / 9:45 AM Occupation: Self-employed
Date & Time Admission : N/A
Date & Time Discharged : N/A
On Examination :
Weight : 70 KG Height : 167 CM BMI : 25
Vital sign :
BP : 156/74 Pulse Rate: 111 Resp. Rate: 20
Temp : 36.5 Pain score : 5/10 SPO2 : 93
If Emergency:
GCS Score : E-3, V-3, M-4 SPO2 : 98% ECG: Abnormal
*Chief Complaint(s).
(Quote the patient’s own word)
- SOB 3/7
DIP MA CUCMS – Clinical Placement [2]
*Present Illness.
(Location, Quality, Quantity or severity, Timing, including onset, duration and frequency, Setting in which they occur, Aggravating and relieving
factor, Associated manifestations)
- Abdominal pain 2/7
- Chest pain 2/7
- Nausea 2/7
- Cough 3/7
- Fever 3/7
- Tightness
*Past History.
Medical History
(eg; diabetes, hypertension, hepatitis, asthma, food and drug allergic, HIV), with date of onset, information about hospitalization with date.
- Hypertension since 2018
- Asthma since 2019
- NKMI ( no know medical illness)
Surgical History
(date, indication and types of operation)
- None surgical history
DIP MA CUCMS – Clinical Placement [3]
Obstetric / Gynecological History
(obstetric history, menstrual history, birth control, sexual preference, any concerns about HIV infection)
- Not know obstetric/ gynecological history
Psychiatric History
(date, diagnoses, hospitalization and treatment)
- None psychiatric history
*Family History.
(Immediate relative, Outline or diagram, Specific Illness and etc.)
Patient Male
Female
- Father have diagnosis asthma since 2019
- Mother don’t have medical illness
*Personal and Social History.
(Occupation, Last year of school, Life experiences, Lifestyle habits, etc.)
- Not smoking
- Married
- He have two children
- Not drink alcohol
- Last year of school is secondary school
- Occupation is self-employed
DIP MA CUCMS – Clinical Placement [4]
*Review of System.
(Head to toe, start with general question, then to specific question and etc.)
About the following subjects:
General. Respiratory. Musculoskeletal.
Skin. Cardiovascular. Psychiatric.
Head, Eye, Ears, Nose, Throat (HEENT) Gastrointestinal. Neurologic.
Neck. Urinary. Hematologic.
Breast. Genital. Endocrine.
Peripheral vascular.
General: weight loss despite increased appetite
- Heat intolerance
- Anxiety
- Irritability
Skin: dry skin
HEENT: Normal
Neck: Normal
Respiratory: Rapid heartbeat
Irregular heartbeat
Chest: Wheezing
Chest abdominal: (inspection, palpation, percussion and auscultation
DIP MA CUCMS – Clinical Placement [5]
PHYSICAL EXAMINATION
(General Survey / General Inspection, Vital Signs,
Skin, Back: inspect and palpate the spine and muscle)
Observation
- Sweaty hand
- Cold SOB
Palpation
- Decrease symmetrically chest wall expansion
Percussion
- Resonance
Auscultation
- Vesicular breath sound with prolong expiration time
Vital Sign
BP: 156/74
PR: 111
SPO2: 93%
Temp: 36.5
Pain score: 5/10
Resp rate: 20
DIP MA CUCMS – Clinical Placement [6]
Differential Diagnosis:
- Bronchial asthma
- COPD
- Congestive heart failure
- Pneumonia
- Allergic rhinitis
- Vocal cord dysfunction
- Panic attack
- Pulmonary embolism
Laboratory test and result:
- Full Blood Count (FBC)
- Red Blood Cell: 8.50x 10^12/L (3.50-5.50) Normal RBC
- White Blood Cell (WBC): 15.79x 1069L (4.0-10.0) Normal WBC
- Hemoglobin: 12.7g/dl (11.0-16.0) Normal HB
- HCT: 39.0% (37.0 – 54.0) Normal HCT
- PLT: 296X 10^9/L
Radiology test and finding :
- Not know radiology test and finding
DIP MA CUCMS – Clinical Placement [7]
Diagnosis : Bronchial Asthma
Management and Treatment:
- Monitoring vital sign
- Auscultation of lung
- Monitor SPO2>95%
- ECG
- Give nebulizer salbutamol 3ml ( 5liter 02 )
Health Education
- Get medication on time
- Always take care of hygiene
- Do not drink cold water or soft drink
- Don’t smoke
Lifestyle and home remedies
- Use your air conditioner
- Prevent mold spores
- Reduce pet dander
- Clean regularly
- Cover your nose and mouth if its cold out
Signature :
siti halijah
…………………………………
Student Name : Siti Halijah Binti Azman
Matric no : DMA 2011-3177
Date and time 12/1/2023 7:30PM
DIP MA CUCMS – Clinical Placement [8]
