Ruj. Kami : (2693) dlm.HSHAS.REK.12.6/14 Tarikh: 30/9/2014Ruj. Tuan : T’loh Rpt.4573/2014Kepada :

Laporan Perubatan (Medical Report)Kementerian Kesihatan Malaysia

Butiran Pesakit (Patient Particulars):

Nama Pesakit (Name of patient):WAN ANISAH BT WAN ROHAMIDUN

No K/P (I/C No) Baru (New): 910322115488 Lama (old):……………….

No Passport (Passport No): ……………………………… MRN: …………………….

Umur (Age): 63DAYS Jantina (Sex): Lelaki (Male) Perempuan (Female)

Tarikh masuk wad atau menerima rawatan buat kali pertama (Date of admission or receiving treatment for the first time) : 11/8/2014

Tempat menerima rawatan (Place where patient received treatment):

Jabatan Kecemasan (Emergency Department) Klinik Pakar (Specialist Clinic) Wad (Ward) ………………………….

Tarikh discaj dari Jabatan Kecemasan (Date of discharge): 28/04/2013

Displin (Discipline): JABATAN KECEMASAN DAN TRAUMA

Sejarah (History):(Including Presenting Complaints, History of Presenting Complaints, Past Medical History, Family History, Social History and Occupational History, Review of Systems, Medical Records Reviewed)Patient and her older brother (Faiz amyshar bin mohd fawwaz) was taken by their mother (Wan anisah binti wan Rohamidun) to the police station to lodge a police report against the father( Mohd fawwaz bin Haji sulaiman)for domestic violence. Upon leaving the police station after lodging a police report, wan anisah, her mother (patient’s maternal grandmother) and her friend were approached by her father in law (Haji sulaiman bin Ahmad). Patient was laying on the lap of a friend (Hamidah binti Hassan ic- 610601065036) at the front seat of the car.Patient’s mother claimed that there was a struggle between Pn. Hamidah and En. haji Sulaiman through a partially opened window in the front seat. En. Haji Sulaiman attempted to pull the child out through the window. Pn Hamidah claims that child had hit her head on the window and both forearms

HOSPITAL SULTAN HAJI AHMAD SHAH JALAN MARAN, 28000 TEMERLOH

PAHANG DARUL MAKMUR.

Telefon: 09-2955333Telefaks: 09-2972468

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were bruised. No other injuries sustained. However, patient started crying inconsolably after that.No open wounds no seizures No vomitting Able to suckle and breast feed as usual after that However mother claims that child cries out whenever she touches the both elbows

Pemeriksaan Fisikal (Physical Examination):(Including general assessment, Eye, ENT, Oral Cavity, Respiratory System, Cardiovascular System, Abdomen, Genitourinary, Central Nervous System, Musculoskeletal, Mental Health Status and Others).

O/e:

Temp (oC): 37 Posture: Lying down SBP (mmHg): 96 DBP (mmHg): 52 Pulse rate (/min): 105 Respiratory rate (/min):26

Patient active on handling, pink anterior fontelle normotensive CRT< 2secs, warm and pink peripheries Good pulse volume

Pupils: 3mm reactive bilaterally good sucking relex Moro;s complete Good grasp relex CVS: DRNM RS: no SCR, no ICR Clear P/A: Soft, not tender Not distended Bowel sounds heard bilateral elbows- redness present on the left>right no bluish discolouration of limbs child does not cry on movement of elbow joints. No swelling radial and ulna pulse palpable

InvestigationBilateral radius and ulna: No fracture seen

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Diagnosis (Diagnosis):

Soft Tissue Injury of left Forearm

Rawatan (Treatment):Child was examined and x ray was reviewed by Dr. Azree To treat as Soft tissue injury of left arm first Bandage left forearm TCA ortho clinic in 1 week for a repeat Xray and reassessment

Rumusan prosedur yang dijalankan ke atas pesakit (summary of procedures carried out on patient):

Bandage of left forearm

Preskripsi ubat-ubat yang diberikan kepada pesakit (drugs and other medicaments prescribed to patients):

No medication prescribed

Perkembangan keadaan pesakit sepanjang di bawah penjagaan doktor termasuk rawatan susulan (progress of patient while under the care of the doctor including follow up):

PATIENT WAS ALLOWED DISCHARGE

Keadaan pesakit ketika berjumpa kali terakhir dengan doktor (condition of the patient last seen by the doctor) : Tarikh (Date) : 20/08/2014

PATIENT REVIEWED IN ORTHO CLINICprogress: mother claimed patient actively moving affected hand tolerating orally well no fever no active complaints

On Examination of left Upper limb: no bruises, not swollen, no erythematous changes child does not cry on movement of elbow joints. radial and ulna pulse palpable

xray of left humerus reviewed: no fracture

Clinical Plan

Discussed with mr yusuf discharge ortho

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Cuti sakit/sekolah (Medical certificate/school leave): NILDari (From) ………………… hingga (to) ………………….

Surat kerja ringan yang diberikan (light duty given): NILDari (From) ………………………. hingga (to) ………………………

Laporan disediakan oleh (Report prepared by):

Nama (Name): DR PRASANNAH SELVARAJAH

No K/P (I/C No): 870611145110 Jawatan (Designation): PEGAWAI PERUBATAN UD 44

Kelulusan (Qualification): MBBS(AIMST) Jabatan (Department): JABATAN KECEMASAN DAN

TRAUMA, HoSHAS

Tandatangan (Signature): …………………. Tarikh (Date): 30/9/2014 Masa (Time) 0800 H

Cop rasmi Hospital (Official Hospital Stamp)

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