CCU B1 Off bladder irigation

Sopiah Bt Yusuff, Off tranexemic acid

80 years old Malay lady Trace FBC
underlying: Restart bladder
HPT, dyslipidemia irrigation if persistent
hematuria
Under medical : For USKUB later

IMP: Anteroseptal, lateral MI, self reperfused, Kilip 2

Initially p/w :
- First episode of central chest pain
- throbbing in nature
- radiate to back
- pain score 8-9/10
- no profuse sweating
Otherwise,
no SOB
no giddiness
no LOC
no nausea/vomiting
no fever
no URTI/AGE sx

Referred to surgical for frank haematuria

Currently
no fever
no SOB
no chest pain
clear in tubing
CCU B3 Restart feeding
Wong Swee Lim Start CF 50cc x3 , if
72 years old tolerated, to start full
Chinese man feeding
Underlying To inform if RT coffee
1) ?COPD ground
2) Chronic smoker Cont IV cefuroxime
3) Right reducible inguinal hernia Cont medical
- since 30 years ago management
- not seek any treatment
4) H/o alleged fall sustained left clavicle fracture and crack
fracture over left acromion in 2014

================================
IMP: small bowel obstruction secondary to right indirect inguinal
hernia
================================

PO Day 6 (15/10/2018 03:10) Right hernioplasty

Surgeon: Dr Hafizi, Dr Farhana
Pre op dx: Right obstructed inguinal hernia
Post op dx: Right indirect inguinal hernia

Operative findings:
Right partially reduced indirect inguinal hernia
Reduced spontaneously on manipulation - visualized bowel healthy
Sac empty
End sac
+ Reactive fluid
No haemorrhagic or foul smelling fluid
Small bowel healthy, not dilated
Spermatic cord identified and preserved

No sample send intraop

=========================================
=========
Currently
intubated
Coffee ground 15 cc
no fever
NBM
ICU BED 5 Cont IV tazocin
Chek Saad Bin Omar Cont anast plan
65 years old malay gentleman
NKMI

Referred form hospital Yan TRO ICB

=========================================
======

Imp: PTD 8 Alleged MVA (MB vs MB 7pm 14/10/18) sustained:

1. Intra-axial and extra-axial haemorrhages with cerebral edema.
- acute subarachnoid haemorrhage seen at right
frontotemporoparieto-occipital, left frontal, interhemisheric fissure,
both tentorial cerebelli, right sylvian fissure, interhemispheric
fissure, perimesencephalic and prepontine cistern.
- contusional haemorrhages at left frontal
- thin subdural haemorrhage at right parietal convexity extending
into posterior interhemispheric fissure measures 0.3cm (thickness)
x 1.5cm (CC).

2. Multiple skull and facial bones fractures

- left side of frontal bone extending to the orbital roof.

- fracture both temporal bone (right > left).
- comminuted fracture left zygomatic bone.
- fracture walls of left maxillary sinus.
- both lamina papyracea.
- fracture left orbital floor, no muscle entrapment.
- walls of posterior ethmoidal air cells extending into anterior wall
of sphenoid sinus with blood products seen within
- both greater wing of sphenoid bone.
- anterior wall of right maxillary sinus extending into right
nasolacrimal duct
- right pterygoid plate.

3. No cervical spine fracture.

under ophthal :
treat as LE traumatic optic neuropathy

=========================================
====
Currently:
Tolerating RT feeding
no vomiting
no fever
ICU Bed 11 for op by ortho team
Muhamad Ilham Azali Bin Ibrahim, today- For right distal
20Y.o, Malay male end radius locking
Unknown medical illness
h/o open appendicectomy in 2014
plate + right distal
femur locking plate
------------------------------------------------------------------------ Cont IV Rocephine
PTD 5 (16/10/2018) alleged MVA (MB vs MB) sustained under
surgical for :
1. Multiple extra-axial haemorrhage with multiple facial and base
of skull fractures
-Acute extradural haemorrhage at right temporal region
- EDH along the left occipital region
2. Grade II liver injury (caudate lobe) with moderate
haemoperitoneum
3. Right lung contusion.
------------------------------------------------------------------------
currently,
Intubated
hemodynamically unsupported
sedated with propofol 10cc/hr
morphine 3 cc/hr
ICU Bed 8 Encourage fluid intake
Mohsin Bin Saaid Cont IV Tazosin
49Y, Male KIV repeat US KUB
Underlying later
1)DM
was on oral hypoglycaemic and insulin
2)BE Glaucoma
- bilaterally blinded
3)H/O Open laparatomy in 2009 for perforated appendix

under medical for

urosepsis TRO pyelonephritis

referred surgical for US abd finding Left mild hydronephrosis with

proximal hydroureter, no stones

presented with suprapubic pain radiating to back for 1 week

-a/w vomiting
Reduced oral intake x 3/7
Fever x 2/7
- chills and rigors
Scrotal swelling gradually increase in size for 2 days

otherwise
no luts sx
no uti sx
no hematuria
no AUR
=========================================
======================================
Currently
having worsening of SOB
no chest pain

21/10/2018
14:54 CT Ureterography Abnormal CT Urography done on
21/10/2018.
Subopatimal examination as patient was scan on decubitus
position, unable to lie supine.

Indication: 49 y/o male. U/L DM, H/O Open laparatomy in 2009

for perforated appendix. Treating under medical for urosepsis TRO
pyelonephritis. US Abd: Left mild hydronephrosis with proximal
hydroureter, no stones. For reassessment.

Findings:
Both kidneys are normal in size, shape and position.
Bipolar length of the right kidney measures 10.9 cm. Parenchymal
thickness measures 1.9 cm.
No calculi or hydronephrosis/ hydroureter seen.

Left kidney is swollen with BPL measures 11.2 cm. Parenchymal

thickness measures 2.1 cm. Mild hydronephrosis and hydoureter
seen till the vesico-ureteric junction, however no calculi / mass
seen.
Moderate perinephric fat streakiness noted. No calculi seen.
Urinary bladder is partially distended with normal smooth wall.

Within the limit of unenhanced CT, the visualized liver, gallbladder,

pancreas, spleen, both adrenals and bowels are unremarkable.
Extensive patchy alveolar opacity noted in both lung bases.
Sclerotic bone lesion seen at left ilium and vertebral body of T10
may represent bone islands.

Impression:
1. Features are suggestive of left pyelonephritis with perinephric
inflammation.
2. Mild left obstructive uropathy, unable to identify the cause.
3. Bibasal severe pneumonia.

Dr Dayana/ Dr Sabariah

-----------------------------------------------------------------------
Exam Performed On : 21/10/2018 10:13 By : HANISAH - Hanisah
Ramli, AZROLHISYAM - AZROLHISYAM, NURFARHANA - Nur
Farhana
Report Prepared On : 21/10/2018 11:58 By : DRDAYANA - Siti
Dayana, DR
Report Authorized On : 21/10/2018 14:54 By Radiologist :
DRSABARIAH - Sabariah, DR

-----------------------------------------------------------------------
ICU BED 18 Cont IV Meropenem
Mohamad Din Bin Che Nik, 43Y, Male Keep drain
Estimated body weight 70kg Cont ICU management
NKMI

=======================================
Post op entering D6 (16/10/2018 at 1200H) Exploratory
laparotomy + Modified Graham patch repair
Pre-Op Diagnosis : Perforated viscus
Post-Op Diagnosis : Perforated pre-pyloric ulcer

Pus upon entering peritoneum, no gush of air

Generalized contamination at subhepatic, subphrenic, pelvic (2.5L)
with interloop collection
Perforated pre-pyloric ulcer at the anterior wall, measuring 1.5cm,
with thickened edge
Small bowel mildly dilated with slough
Loose adhesion of omentum to the perforation site and anterior
abdominal wall
Liver, gallbladder, spleen normal

* pt was on IVI Noradrenaline 10-14 ml/hr upon induction and

weaned down to 1 ml/hr towards closure

EBL: minimal

HPE sent: ulcer edge ; on hold

=======================================
currently,
no fever
no abdominal pain
no old melena
patient restless,tachypnic under CPAP--> started midazolam
BR1 Bed 6 MMT
Che Zuraifah Bt Ahmad Zabidi Cont IV Nexium 40mg
55 y.o/malay/ lady BD
KIV OGDS cm after
wife to HOD ENT Mr Hisham d/w Mr Chong
currently admitted in BR 1 under ENT for: Send Urine diatase
- chronic rhinusinusitis
- ddx: ?trigeminal neuralgia for US abdomen on
25/10/18
case referred to Surgical for gastritis

k/c/o
Under Surgical
- Ulcerative colitis since 1995 -with anterior uveitis
- Reflux esophagitis
- Right lobe liver hemangioma (3.8 x 3.2 cm)
- Right renal hydronephrosis secondary to ureteric calculi

Others:
- Degenerative disc disease at L5/S1 level since 2010
- Left cataract removal - 2006, in HSB
- FESS for sinusitis - 2010, in HSB
- Left carpal tunnel syndrome
- Bipolar disorder, - depression
- Bronchial asthma
- Menopause on HRT
- Left ovarian cyst removal in 1995 GERD and ulcerative collitis

OGDS x 2
- 10/12/13: prepyloric erosions
- 10/3/16:
superficial erosions noted over prepylorus area
small pedunculated papillae noted at the 30 cm from incisor
HPE: Squamous Papilloma

Last on T nexium 40 mg BD on 09/11/16

Previous USG Abdomen 2/11/16
- Findings:
Liver is normal in size and echogenicity. There is a well defined
homogenous hyperechoic lesion measuring 3.8 x 3.2 cm noted in
right lobe of liver. Rest of liver parenchyma appears normal. No
dilated ducts. Gallbladder is distended with no gallstone.
Spleen and the visualized pancreatic body are normal.
Both kidneys are normal in sizes with good cortical thickness and
corticomedullary differentiation.
BPL of the RK is 10.2 cm and LK is 10.3 cm.
No bilateral renal stone and hydronephrosis seen.
No adrenal mass.
No ascites.
Urinary bladder is underfilled.
No pelvic mass seen.
- IMP:
1. Right lobe liver haemagioma.
2. No other significant abnormality seen.

HOPI:
p/w: sudden onset of epigastric pain x 1/7
radiating to the left side of the abdomen
claims severe p/s: 8-9/10
a/w: bloatedness
=========================================
=======================
Currently
Having stomach bloatness
claim still having abdominal pain
K9 Bed 19 Cont CF
KIV allow NF if no
vomiting cm
SHARIPAH BINTI ALI,
51Y, Female

POD3: total abdominal hysterectomy bilateral

salphingoopeherectomy and adhesiolysis with primary sigmoid
colon repair, with diverting proximal sigmoid colostomy

Pre OP Diagnosis : Multiple uterine fibroid

Post OP Diagnosis : Multiple uterine fibroid with sigmoid colon
perforation
Operative Findings : Uterus 22weeks size with multiple uterine
fibroid
omentum adhered to anterior abdominal wall and left anterior part
of uterus
dense adhesion over right pelvic wall, small bowel and right
anterior of uterus
sigmoid colon adhered to posterior part of uterus
bilateral tubes and ovaries normal
bladder high up
liver normal
hysterectomy done in 2steps, morcellation of fibroid to reduce size
to allow space for surgery to be done, however noted sigmoid
colon perforation. called in Mr Rashide.
Then releasing the adhesion by Mr Rashide and surgical team.
Total hysterectomy done after releasing the adhesion.
Subsequently sigmoid colon repair and colonostomy done by
surgical team.

**TBL 2.6L, tranfused 3pint WB and 1 cycle DIVC intra-op**

**counselling with family members by Dr Sushil; unfortunately no

family members available at waiting area, only 'adik angkat' name
Erneni, passport AT789103. Counselled her regarding the
operative findings of huge uterus with multiple uterine fibroid and
adhesions due to previous surgery. Adhesiolysis done with surgical
team, however, patient had sigmoid colon perforation. Repair was
done by surgical team and requiring colostomy. This is the
complicatoin of the surgery due to the adhesion from the previous
myomectomy. patient also suffered massive blood loss about 2.6L,
requiring blood transfussion 3pint WB and 1cycle DIVC. She
understood and inform her to inform other family members so that
they will be updated regarding patinet's condition at 8.30am at
HDA k9
=========================================
=============================
currently,
no fever
tolerable abdominal pain
tolerating CF
K8 Bed 25 robert suction
Siti Farah Binti Mohd Roseli CXR cm
26 years old, malay lady
U/L:
1. Sputum + PTB now on Maintenance phase HR dose 5/120
completed intensive phase 56 dosesSHRE
History of drug induced dermatitis (from skin HPE) and hepatitis
during intensive phase

2. PTB with left trapped lung

- history of left pleural needle aspiration- failed

Under medical for:

PTB diagnosed by Gene Xpert with persistent left pneumothorax
and hx of drug induce hepatitis ( currentyl resolved)

Refer to surgical for Robert suction

Chest tube inserted on 16/10/18

Unable to off chest tube on D5

Chest tube: bubling today

Currently
No fever
No worsening SOB
K4 Bed 17 Trace CT formal report
Ahmad Shukri Bin Saman
66/ Malay / Man KIV for open
case of Squamous cell carcinoma larynx gastrostomy after d/w
post ELMS and laser surgery done on 21/12/15 specialist
staging - T2N0M0

patient had completed adjuvant radiotheraphy (25/4/16)

CT scan post radiotherapy
Impression:
Known case of Squamous cell carcinoma of larynx, features
suggestive of post radiotheraphy soft tissue thickening causing
supraglottic laryngeal stenosis. However recurrence cannot be
totally excluded. Suggest clinical or scope or biopsy correlation.

Under ENT for

- CA larynx with dysphagia
- Covering for CAP
----------------------------------------------
HOPI:
pt started to have dysphagia x 1/12 ago
worsening for x 2/52
unable to tolerate solid and fluid
lethargic
LOW
LOA

no fever
no headache/giddiness
no SOB / Chest pain
no abd pain
----------------------------------------------
Referred to surgical for PEG tube insertion
Proceeded with OGDS on 18/10/18 by Mr Kong
- Findings:
swollen arytenoid with narrowing larynx
unable to pass through cricopharyngeal junction ,
narrowing with soft tissue lesion , ? stricture ? ingrowth
pharyngeal tumour ( photo)
- Post-procedure Instructions :
for NF
oral intake charting
For Open Gastrostomy If familly keen
For family to purchase replacement tube (to arrange with scope
room)
KIV for op date once family keen and able to purchase.
----------------------------------------------
Currently:
Unable to tolerate feeding
On IV Unasyn D4
No fever
M1 Bed 6 Cont supervised oral
Nur Damia Qalesya Binti Mohd Haizarul, 3Y3M feeding
regular tepid sponging
Post MVA D17 (Car vs lorry 4/10/2018) cont paeds
1) Right sided 3-8th rib fracture with bilaterla lung contusion and management
right hemothorax daily surgical review
2) grade 2 splenic injury
3) grade 3 right kidny injury
4) SAH with multiple base of skull
2) MRSA pneumoniae
referred to HSAH for continuation of care due to logistics reason

Currently
Fever setteling down
Tolerate RT feeding
PU BO normal
K5 Bed 25
KNBM
Start IVD
Chew Tat Choo
Transfuse another PC
56 years old Chinese man
Repeat FBC cm
Underlying:
Start IVI Pantoprazole
1) DM
KIV for OGDS
2) HPT
Withold
3) CKD - eGFR 23 (advise to avoid traditional medication and
NSAID/anticoagulant/a
painkiller by medical team)
ntiplatelet/traditional
4) Gout
medication
-under MOPD f/up
Inform if s/sx of active
--------------------------------------------------------------------------
bleeding
---------
Surgical r/v cm
Imp:
Dislodged external fixation with SSI at medial calcaneum pin site

Referred surgical for UGIB

Noted in ward :
1st episode of hemoptysis in ward,
noted hb dropped from 10.5 to 7.3
otherwise, vital signs stable
to transfused 1 pint PC (20/10/2018)
post transfusion hb 7.6

Currently
No vomiting
no PR bleed
No anemic sx
Done Coloscope until 60cm - hemorrhoid at 11oclock - banding
done in 2015
K7 Bed 21 NBM first
To corect
coagulapathy - cont
Jacob A/l P.c. Woomen
transfuse FFP as plan
72 year old male
Start IV Vitamin k
underlying:
To review AXR, CXR
1) mental retardation - OKU card holder
erect
2) 1st degree heart block with mild postural drop - under MOPD
Start IV Tranexemic
acid
Referred surgical to review for acute abd
KIV for US abdomen
imp
infective AGE in shock
UGIB

currently
No fever
No melenic stool/ passing out blackish stool
noted coffee ground on RT
K8 Bed 15 Preop assessment
Allow to proceed with
Siti Sarah Binti Md Salleh op
High risk consent
IMP: ICU Back-up
1) Fluid overload secondary to underlying advanced CKD For op under GA/IPPV
2) AKI on CKD secondary to perinephritic abscess with invasive
3) Left hand cellulitis (resolved) monitoring intra-op
GXM 4pints to OT
Operation planned :    Left nephrectomy For antihistamine
Diagnosis  :    Left emphysematous pyelonephritis 30minutes prior to
transfusion (Patient
allergic to plasma
Premorbidly NYHA III, METS<4. protein)
SOB after walking ~100m ABG
+orthopnea +PND Keep BP <140/90
Homebound. To optimize
ADL independent antihypertensive
 
Underlying
S/T SN Rozita (urology
1) Left emphysematous pyelonephritis clinic)
-Done I&D of left perinephric abcess on 9/11/17 done under GA , TCA urology clinic on
admitted to ICU post op for septic shock 30/10/18
-Done CT guided drainage of left perinephric collection on 01/4/2018 - to bring referral
-CECT Abdomen and Pelvis done on 26/3/2018 letter, relevent blood
Impression: ix and radiological
1. Persistant left perinephric abscess collection. (size 5.2cm(AP) x films
7.6cm(W) x 9.8cm(CC).)
2. Irregular left kidney with patchy hypodensities in keeping with Surgical review PRN
patchy nephronia or previous residual small abscesses. - need to do referral
3. Splenic microabscesses. letter, relevent blood
4. Left double J stent in situ. (Double J stent seen with the tips ix and radiological
proximally at upper pole of left kidney and distally at the left films upon discharge
vesicoureteric junction within the bladder cavity)
-US KUB 21/8/2018:
Impression:
1. Left perinephric collection.
2. Right grade II renal parenchymal disease.
2. Bilateral pleural effusion
-CTU 6/9/2018:
Impression:
1. Residual scanty left perinephric fluid not amendable for drainage
with inflammed perinephric fat.
2. Swollen left psoas muscle. Suggest clinical correlation and follow
up ultrasound to exclude early abscess formation.
3. Bilateral tiny nephrolithiasis, with no obstructive uropathy.
4. Worsening bilateral pleural effusion.
-USS KUB 4/10/2018
Impression:
1. Marginally unchanged left perinephric collection. Suggest CT for
reassessment.
2. Changes in the left kidney and the adjacent left psoas muscle
suggestive of inflammatory changes secondary to (1).
3. Right grade II renal parenchymal disease.
4. Mild ascites.
5. Bilateral pleural effusion.
- planned by Urology team HSB for left nephrectomy.Patient was
seen previously seen in Uro clinic ,patient septic looking and not fit
for surgery.
Suggested by Uro HSB to refer anaes HSAH for pre-op assessment
for nephrectomy, if fit for nephrectomy, to TCA Uro clinic HSB for
further plan.
.
2) DM
-diagnosed since 17 years old
- On S/C Actrapid 18 units TDS and S/C insulatard 18 units ON
- on T. Metformin 1g BD
- under KK Bedong follow up previously, now under MOPD
- Right diabetic retinopathy since 2015

3) Advanced CKD approaching ESRF

- planned for long term RRT
-on fluid restriction 500mls/day
- **to spare left hand

4) HPT
-on T. Metoprolol 100mg BD & T. Felodipine 10mg BD
 
5) History of transfusion reaction on previous admission
- transfusion reaction workout: Allergic to plasma protein
- for antihistamine 30 minutes prior to next transfusion and for slower
transfusion

ICU Bed 12 VS monitoring hourly

Preme Kumar Jude A/l Pius Francis till stable then 4
66y/0 Indian gentleman hourly
Post op to ICU
Keep NBM for 7 days
Post op 2 H Subtotal gastrectomy + Roux En Y gastro- Cont TPN
jejunostomy for Locally advanced pyloric tumour with gastric To get oral contrast
outlet obstruction study on day 7 post op
(28/10/18) - to assess
Operative finding : patency of the G-J and
Omental adhesion from previous surgery to anterior abdominal wall, J-J anastomosis
subhepatic and lesser sac region Epidural analgesia as
No ascites, no peritoneal nodule per anaesth
Liver is smooth , no palpable nodule IV Cefobid 1 g BD and
Hard tumor at pylorus with posterior infiltration to transverse IV Flagyl 500mg TDS
mesocolon Keep current Ryles
Distended stomach proximal to the tumour tube
Left gastric vessel identified and preserved DO NOT ADJUST OR
No obvious enlargement of perigastric lymph nodes RE-ANCHORED RYLES
Gall bladder, spleen, colon normal  TUBE (IF DISLODGED)
- anchored at 55cm
WI Day 2 ( 23/10/18)
STO D10 (31/10/18)
EBL: 800cc, Intraop transfused 1 pint WB Keep drain tube and
charting
Specimen: subtotal gastrectomy with attached omentum Cont IV Pantoprazole
from previous omentoplasty 40MG bd
Strict I/O charting
Trace HPE
 tagged with short suture at superior margin, and long Chest/ Limb physio
suture at distal margin (duodenum)
Ex-vivo examination of specimen:

- Hard circumferential tumour at pylorus