1. 1. history
1.1. pt history
1.1.1. past medical hx
1.1.1.1. semenjak bila
1.1.1.2. ubatan/rawatan yg digunakan
1.1.1.2.1. ubatan hpt @DM
1.1.1.3. komplikasi sekiranya ada
1.1.1.3.1. stroke
1.1.2. past surgical hx
1.1.2.1. bilakah pembedahan tersebut
1.1.2.2. lokasi pembedahan
1.1.2.3. adakah pembedahan tersebut elektif atau emergency
1.1.2.3.1. why we need to know it is emergency or elective
1.1.2.4. komplikasi sekiranya ada
1.1.2.4.1. bleeding
1.1.2.4.2. infeksi
1.2. nutrition history
1.2.1. jadual pemakanan
1.2.1.1. tabiat makan mengikut jadual @ tidak
1.2.2. jenis pemakanan
1.2.2.1. pedas
1.2.2.2. berempah
1.2.2.3. fast food
1.2.3. kepercayaan pantang larang
1.2.3.1. mengikut kepercayaan agama masing
1.2.3.1.1. orang melayu - masak lemak menggunakan santan
1.2.3.1.2. orang cina - lebih kepada masakan sup
1.2.3.1.3. orang india - lebih kepada kari yang sedap.
1.2.4. pemakanan
1.3. family history
1.3.1. genetik
1.3.1.1. cancer
1.3.2. penyakit keturunan
1.3.2.1. DM / HPT/ Heart Problem
1.4. keadaan kesihatan semasa
1.4.1. jenis sakit History of the present illness, presence of pain P-Q-R-S-T Tool to Evaluate Pain
1.4.1.1. P: What provokes symptoms?
1.4.1.1.1. sebab sebab yang menimbulkan gejala sakit samada melakukan aktiviti @ selepas makan @ pun semasa berehat
1.4.1.2. Q - Quality and Quantity of symptoms:
1.4.1.2.1. Is it dull, sharp, constant, intermittent, throbbing, pulsating, aching, tearing or stabbing?
1.4.1.3. R: Radiation or Region of symptoms:
1.4.1.3.1. Does the pain travel, or is it only in one location? Has it always been in the same area, or did it start somewhere else?
1.4.1.4. S: Severity of symptoms or rating on a pain scale.
1.4.1.4.1. Does it affect activities of daily living such as walking, sitting, eating, or sleeping?
1.4.1.5. T: Time or how long have they had the symptoms.
1.4.1.5.1. Is it worse after eating, changes in weather, or time of day?
1.5. eliminasi
1.5.1. corak BO
1.5.1.1. tidak teratur/ masa sentiasa berubah
1.5.1.1.1. menunjukkan masalah pada colon
1.5.2. diarrae/constipation
1.5.3. kandungan najis
1.5.3.1. terdapat darah @ lendir (gangguan dalam penyerapan di colon)
1.5.3.1.1. Tarry black colour ( Hematochezia)
1.5.3.1.2. maleana stool
1.5.3.1.3. Steatorrhea (Fatty Stool)
1.5.3.1.4. foamy stool @ frothy stool
2. physical assessment
2.1. general condition
2.1.1. letih lesu
2.1.2. pucat
2.2. perubahan warna kulit
2.2.1. jaundice
2.2.2. bruishing
2.2.3. itching
2.3. perubahan tanda vital
2.3.1. basik vital sign
2.3.1.1. BP
2.3.1.1.1. bacaan high @ low
2.3.1.2. pain score
2.3.1.2.1. 0 - 10
2.3.1.3. pulse
2.3.1.3.1. tachycardia?
2.3.1.4. temperature
2.3.1.4.1. temp high ?
2.4. pemeriksaan spesifik bahagian abdomen
2.4.1. inspection (4S)
2.4.1.1. 1. perubahan pada warna kulit -nodule, lesion, scarring, discoloration, inflamation, bruising, striae
2.4.2. palpation
2.4.2.1. light palpation - tenderness/muscular resistance
2.4.2.2. deep palpation - kenalpasti mass
2.4.3. Percussion
2.4.4. auscultation