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HOSPITAL SULTAN HAJI AHMAD SHAH

JALAN MARAN, 28000 TEMERLOH


PAHANG DARUL MAKMUR.
Telefon: 09-2955333
Telefaks: 09-2972468

Ruj. Kami
Ruj. Tuan
Kepada

: (2693) dlm.HSHAS.REK.12.6/14
: Tloh Rpt.4573/2014
:

Tarikh: 30/9/2014

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):


Umur (Age): 63DAYS

Jantina (Sex):

MRN: .

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
(patients 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.
Patients 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
were bruised. No other injuries sustained. However, patient started crying inconsolably
1

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

Investigation
Bilateral radius and ulna: No fracture seen

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 CLINIC
progress:
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

Cuti sakit/sekolah (Medical certificate/school leave): NIL


Dari (From) hingga (to) .
3

Surat kerja ringan yang diberikan (light duty given): NIL


Dari (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)