Clinical Anatomy & Documentation Guide

1. 📚 Cara Menggunakan Modul

Gunakan modul ini daripada:

ANATOMY → LOCATION → SYMPTOM → CHARACTER → ASSOCIATED FEATURES → EXAMINATION → DIFFERENTIAL → DOCUMENTATION

Matlamat dokumentasi bukan sekadar menulis nama penyakit. Dokumentasi klinikal yang baik menerangkan apa yang pesakit adu dan apa yang ditemui semasa pemeriksaan.

Contoh:

❌ "Appendicitis."

Lebih baik:

✅ "Acute right lower quadrant abdominal pain, progressively worsening, associated with nausea and anorexia."

2. 🧍 Anatomi Badan Manusia

2.1 Body Regions

Head
Cranial region
Facial region

Neck
Cervical region

Chest
Thoracic region

Abdomen
Abdominal region

Pelvis
Pelvic region

Back
Dorsal region

Upper Limb
Shoulder → arm → forearm → hand

Lower Limb
Hip → thigh → leg → foot

Spine
Cervical → thoracic → lumbar → sacral

2.2 Medical Directional Terms

Term	Maksud	Contoh
Anterior	Bahagian hadapan	Anterior chest
Posterior	Bahagian belakang	Posterior neck
Superior	Ke arah atas	Superior to the umbilicus
Inferior	Ke arah bawah	Inferior to the ribs
Medial	Menghampiri garis tengah	Medial aspect
Lateral	Menjauhi garis tengah	Lateral aspect
Proximal	Lebih dekat kepada origin	Proximal arm
Distal	Lebih jauh daripada origin	Distal finger
Superficial	Lebih dekat permukaan	Superficial wound
Deep	Lebih dalam	Deep tenderness

2.3 Common Anatomical Terms

Term	Clinical meaning
Cranial	Relating to skull/head
Cervical	Neck
Thoracic	Chest
Abdominal	Abdomen
Pelvic	Pelvis
Lumbar	Lower back
Gluteal	Buttock region
Inguinal	Groin
Axillary	Armpit
Popliteal	Behind knee
Palmar	Palm of hand
Dorsum	Back surface of hand/foot

3. 🔥 Pain — Medical Terminology

3.1 Character of Pain

Term	Maksud	Contoh
Sharp	Sakit tajam	Sharp chest pain
Stabbing	Seperti ditusuk	Stabbing pain
Burning	Rasa terbakar	Burning epigastric pain
Dull	Sakit tumpul	Dull abdominal ache
Aching	Lenguh / sakit berpanjangan	Aching back pain
Cramping	Seperti kekejangan	Cramping abdominal pain
Colicky	Datang secara gelombang	Colicky flank pain
Throbbing	Berdenyut	Throbbing headache
Pressure	Rasa tekanan	Chest pressure
Tightness	Rasa ketat	Chest tightness

3.2 Pain Severity

Score	General description
0/10	No pain
1–3/10	Mild
4–6/10	Moderate
7–10/10	Severe

Pain score ialah subjective assessment. Gunakan skor yang diberikan oleh pesakit, bukan andaian pemeriksa.

3.3 OPQRST / SOCRATES

O — Onset P — Provocation / Palliation Q — Quality R — Region / Radiation S — Severity T — Time

Component	Soalan
Onset	Bila bermula? Sudden atau gradual?
Provocation	Apa yang menyebabkan lebih teruk?
Palliation	Apa yang mengurangkan sakit?
Quality	Sharp? Burning? Cramping?
Region	Di mana lokasi sakit?
Radiation	Adakah sakit merebak?
Severity	Berapa /10?
Time	Berapa lama dan berapa kerap?

4. 🩹 Wounds & Injury Documentation

4.1 Types of Wounds

Term	Maksud
Abrasion	Luka akibat geseran
Laceration	Luka koyak
Incised wound	Luka potong
Contusion	Lebam akibat trauma
Puncture wound	Luka tusukan
Ulcer	Kehilangan tissue yang berpanjangan
Burn	Thermal/chemical/electrical injury

4.2 Wound Documentation

SITE → LENGTH → WIDTH → DEPTH → WOUND BED → EDGE → EXUDATE → SURROUNDING SKIN → ODOUR → PAIN → SIGNS OF INFECTION

Contoh:

"Approximately 2 cm × 1 cm wound over the anterior aspect of the right lower leg. Wound bed appears superficial. Minimal serous exudate noted. Surrounding skin without obvious erythema."

5. 📝 General Clinical Documentation

SITE + ONSET + CHARACTER + SEVERITY + RADIATION + TIMING + ASSOCIATED SYMPTOMS + RELEVANT NEGATIVES + EXAMINATION FINDINGS

Contoh general:

"Patient reports acute right-sided abdominal pain for 8 hours. Pain is constant, severity 7/10, with associated nausea. No diarrhoea reported."

"Abdomen tender over the right lower quadrant on examination."

Bezakan:

Symptom: apa yang pesakit rasa.
Sign: apa yang diperhatikan/ditemui oleh pemeriksa.
Diagnosis: clinical conclusion selepas assessment yang sesuai.

6. 🫃 Abdomen — Anatomy

6.1 Four Abdominal Quadrants

RUQ
Right Upper Quadrant

Liver
Gallbladder
Duodenum
Right kidney
Colon

LUQ
Left Upper Quadrant

Stomach
Spleen
Pancreas
Left kidney
Colon

RLQ
Right Lower Quadrant

Appendix
Caecum
Terminal ileum
Right ureter
Pelvic structures

LLQ
Left Lower Quadrant

Sigmoid colon
Descending colon
Left ureter
Pelvic structures

6.2 Nine Abdominal Regions

Right hypochondriac
Liver, gallbladder

Epigastric
Stomach, duodenum, pancreas

Left hypochondriac
Spleen, stomach

Right lumbar
Right kidney, ascending colon

Umbilical
Small bowel

Left lumbar
Left kidney, descending colon

Right iliac
Appendix, caecum

Hypogastric
Bladder, pelvic organs

Left iliac
Sigmoid colon

6.3 Major Abdominal Organs

Liver
Hepatobiliary system

Gallbladder
Biliary system

Stomach
Upper GI tract

Pancreas
Digestive/endocrine organ

Spleen
Lymphoid organ

Small intestine
Duodenum, jejunum, ileum

Large intestine
Colon and rectum

Kidneys
Retroperitoneal organs

Ureters
Urinary tract

Urinary bladder
Pelvic urinary organ

7. 🩺 Abdominal Pain — Location → Differential

Location	Common differential considerations
Epigastric	Dyspepsia Gastritis Peptic ulcer disease GERD Pancreatic disease Biliary disease
RUQ	Biliary disease Cholecystitis Hepatobiliary disease Gastric/duodenal disease
LUQ	Gastric disease Splenic pathology Pancreatic pathology Colonic pathology
Periumbilical	Early appendicitis Gastroenteritis Small bowel pathology
RLQ	Appendicitis Ileitis Ureteric pathology Pelvic/gynaecological causes
LLQ	Diverticular disease Colonic pathology Constipation Pelvic/gynaecological causes
Suprapubic	Cystitis Urinary pathology Pelvic pathology
Flank	Ureteric stone Pyelonephritis Renal pathology Musculoskeletal pain

Lokasi sakit sahaja tidak cukup untuk menentukan diagnosis. Gunakan history, examination, vital signs dan pemeriksaan tambahan apabila berindikasi.

8. 📋 Abdomen — Disease → Pain Pattern → Documentation

8.1 Gastritis / Dyspepsia

Typical pattern: Epigastric discomfort, burning, bloating atau nausea.

Documentation:

"Patient reports epigastric burning pain for 2 days, intermittent in nature, severity 4/10, associated with dyspepsia and nausea."

Jangan menetapkan gastritis hanya berdasarkan lokasi epigastric pain.

8.2 Peptic Ulcer Disease

Epigastric pain/discomfort. Hubungan dengan makanan boleh be