TARIKH D: O/A: Conscious, alert,not M/X: Cover for ACS

26/5/2023 60 years old malay gentleman tachypneic 1) VITAL SIGN

C/O: 2) NP3L
MRN: 3) IVL + BTL
631109107751 SOB x1/7 -since 1 am today 4) ECG – LBBB, T wave inversion over V5-V6
while pt was watching tv O/E: 5) CXR -
+chest discomfort since 1am GCS full
+on and off palpitation warm pink peripheries, CRT
6) MEDICATION – Start S/C Fondaparinux 2.5mg
<2sec, good PV
STAT and OD T.Aspirin 300mg STAT and 150mg OD
U/L: Lungs : Clear
T.Plavix 300mg STAT and 75mg OD T.Atorvastatin 40mg ON
1/Hypertension No pedal edema
IV Pantoprazole 40mg STAT and OD
1/ Hypertensive emergency VT :
with APO secondary NSTEMI 7) Refer Medical
BP 163/109 HR 99 RR 21 T 36.2
-TIMI: 3 - Trop T 110 (high) spO2 98% RA DXT 7.2
2/ AKI on CKD secondary to
1)

TARIKH D: O/A: Alert Not tachypneic Good M/X: Cover for ACS
26/5/2023 56 year old malay gentleman pulse volume 1) VITAL SIGN
2) NP3L
MRN: 3) IVL + BTL
670806035599 C/O: 4) ECG – ECG ST elevation at AVR and aVL, ST
Right sided chest pain since O/E: GCS full, Good pulse depression in II, III, aVF, V3-V6
2am today woken up from volume, Lungs: clear, equal air 5) CXR -
sleep due to pain +SOB entry, No pedal edema 6) MEDICATION – Tab Aspirin 300mg stat and 150mg
+Palpitation +profuse
OD Tab Plavix 300mg stat anD 75mg OD Tab Atorvarstatin
sweating
40mg ON S/C Fondaparinux 2.5mg stat and OD IV Morphine
1mg stat and PRN
VT : BP: 104/60 HR: 71 T: 36.3 7) Refer Medical
U/L: HPT, Gout, SPO2: 98% under RA DXT 6.0
Gastritis,Acute high lateral pain score 4/10
STEMI complicated with VF
and cardiac arrest @
 11/5/2023

TARIKH D: O/A: M/X: 1/ CVA

26/5/2023 73 years alert, pink, not tachypnoiec 1) VITAL SIGN
old,MALE,CHINESE 2) NP3L
MRN: 3) IVL + BTL
500309105101 4) ECG – SR
C/O: O/E: 5) CXR –
upon awakening from sleep at crt<2s warm peripheries good 6) CT BRAIN- left temporo-occipital infarct
0600H noted patient unable to pulse volumeM gag reflex: weak,
get out from bed noted 6) MEDICATION – to serve T Aspirin 150mg stat
pupils 3/3 reactive bilaterally +
slurring of speech last seen insert RT
left facial asymmetry + slurring of
well at around 0300H 8) IVD 3PINT 24H
speech
7) Refer Medical

U/L:1/ Hypertension 2/ VT : HR 72 BP 107/62 spo2 96%

Dyslipidemia under RA DXT 6,GCS E1,V1,M4

TARIKH D: O/A: M/X: TRO CVA

56/MALE/INDIAN unconscious not tachypneic 1) VITAL SIGN 1) Acute delirium
26/5/2023 secondary to sepsis
2) FM3L
MRN: secondary to DFU
3) IVL + BTL
580805085405 O/E:
C/O: 4) ECG – SR
 Was found unconscious on
bed by wife at 1.30pm
Son claims that patient has
been having 1) Loose stools x
4/7 - 1 watery stools each day;
2x watery stools yesterday 2)
Abdominal distension x 4/7 3)
Hiccups x 4/7 + nausea x 4/7
O/E E2V1M1,warm peripheries, ,
not tachycardic
VT :
BP 130/72 HR 86 SPO2 98%
under RA DXT 22.8 Ketone 0
5) CXR - Left lung haziness
Foot X-ray reviewed: Left foot +OM changes
6) MEDICATION – start IV Unasyn 1.5g stat and TDS
start insulin sliding scale 2
7) Refer Medical
refer ortho for DFU

U/L:
1) HPT 2) Dyslipidemia 3)
DM 4) History of CVA in
2022 - right-sided hemiparesis
5) DFU

TARIKH D: O/A: M/X: Spontaneous right side

26/5/2023 58/MALE/MALAY alert, conscious 1) VITAL SIGN pneumothorax
2) HFM15L
3) IVL + BTL
MRN: C/O: O/E: 4) ECG – SR
660206045487 SOB x4/7 Chronic chough Lungs reduce a/e at right side 5) CXR - Right side pneumothorax
x1/12 - Dry Sore throat x2/52 chest tube/seldinger insertion

6) MEDICATION – MORPHINE 1MG STAT,

U/L: VT : FENTANYL 50MG STAT
BP 129/87 PR 89 SPO2 97% 7) Refer Medical
under FM5L/min
TARIKH D: O/A: M/X:
30/MALAY/FEMALE Alert conscious Pink Not 1) VITAL SIGN
tachypnoec 2) RA
MRN: 3) IVL + BTL
930726106244 C/O: 4) ECG – SR
Fever - 2/7 Cough since last O/E: 5) CXR -
week - greenish sputum - pulse good volume CRT <2sec
6) MEDICATION – IV AUGMENTIN,TAB
pleuritic chest pain Runny warm peripheries
Lungs clear AZITHROMYCIN
nose - 2/7 Sore throat - 2/7
Vomiting x 3 today 7) Refer Medical
VT :
BP 137/86 PR 120 T 37.1 SPO2
U/L: 100% on RA dxt stat 10.3
1. DM 2. h/o Covid19 Cat 5 in
July 2021

TARIKH D: O/A: M/X: Anteroseptal STEMI Killip

62/MALE/MALAY Alert, 1) VITAL SIGN I
Not tachypneic, 2) NP3L
MRN: 3) IVL + BTL
610403026001 C/O: O/E: 4) ECG – Tall T wave at V2-V4, STD at II and V5-V6
1) Back pain x1/7 - about full GCS ECG post strep 30mins: STE resolving with TWI at V2-V4
10am, patient was gardening - not tachycardic and TWI at V5-V6
Good PV, CRT<2s, warm
crushing in nature, radiating to 5) CXR - V2-V4 and TWI at V5-V6
epigastric region peripheries Lungs: clear No pedal
edema 6) MEDICATION – T Aspirin and T Plavix 300mg stat,
 S/c Fondaparinux 2.5mg stat at 12pm IV Streptokinase 1.5M
VT : BP 140/92 PR 64 SpO2 96% units over 1H given (12.35pm-1.35pm)
U/L:1) HPT under RA 7) Refer Medical

TARIKH D: O/A: M/X: Treat as ACS

4/5/2023 18/MALE/MALAY 1) VITAL SIGN
2) RA
MRN: 3) IVL + BTL
050915100655 C/O: O/E: 4) ECG – ECG: STE over I, aVL, V2 and STD over III,
1/ chest pain x 2/7 - sudden alert GCS full not tachypneic not Avf
onset , came in 3 episodes - tachycardia good pv warm ECG x 2: SR, no more STE or STD seen
lasted for an hour - sharp pain peripheries CRT < 2s no radial- 5) CXR - no cardiomegaly, lung fields clear
over right side, non radiating - radial delay no radiofemoral delay 6) MEDICATION – start T Aspirin 300mg stat and
relieved upon leaning forward Lungs clear 150mg OD Start T Plavix 300mg stat and 75mg OD
- ps 5/10 2/ SOB 3/
7) Refer Medical
diaphoresis 4/ coughing x 4/7
- non productive
VT :
BP 136/85 PR 61 T 37 spo2 98%
under RA
U/L:
TARIKH D: O/A: M/X: Symptomatic SVT 2ndary
4/5/2023 40 years old, malay, lady 1) VITAL SIGN to ACS
2) NP3L
3) IVL + BTL
MRN: C/O: O/E: 4) ECG – ST depression over v3-v5, svt
830827086408 palpitation sudden onset alert, not tachypneic, good PV, ECG post cardioversion- sinus tachycardia
arounf 2.30am a/w localized CRT <2s 5) Done vagal maneuvers → not resolved given IV Adenosine
left sided chest pain + sob + equal a/e, clear 6mg – 8mg- 12mg- 18mg but still SVT given IV verapamil
claims missed medication on cardiac monitor shows SVT 5mg x1- not resolved
off for the past 1/52 ynchronized cardioversion
VT :141/86 PR 160-180 RR 32 T given IV midamorphine prior cardioversion synchronized
37.2 spo2 100% under RA cardioversion done x1 (100J) → SVT resolved
U/L: 5) CXR - no cardiomegaly, lung fields clear
DM HPT HPL
6) MEDICATION – S/C clexane 60mg OD
7) Refer Medical

1) breakthrough seizure TRO

TARIKH D: O/A: M/X: cause 2) spontaneous right
4/5/2023 frontal intraparenchymal bleed

MRN: 1) VITAL SIGN

630627075871 C/O: O/E: 2) hfm3l
ongoing fiting clinically pink, good pule volume 3) IVL + BTL
crt <2 warm peripheries ++ 4) ECG – sr
stridor pupil 2mm reactive
Intubate ett 7.4, anc 20
 U/L: bilaterally Sedated with ivi midafent 30mg in 30ml ns run 3ml/h
epilepsy LUNGS : transmitted sound Ryles tube n cbd
Ctb - right frontal intraparenchymal bleed
VT : Cxr- clear, no cardiomegaly
BP 105/62 PR 160 Spo2 90% 6) MEDICATION – TDM sodium valproate low On IV
under HFM15L/min TEMP 37.3 Na Valproate 400mg TDS IV Phenytoin 100mg TDS,On IV
DXT 9.2 Augmentin 1.2g TDS D4
7) Refer Medical and anaest

TARIKH D: O/A: M/X: treat as ACS

4/5/2023 67 Malay Female
1) VITAL SIGN
MRN: 2) ra
540513015492 C/O: O/E: 3) IVL + BTL
SOB and chest tightness for alert and orientated 4) ECG – SR 71, T inv 1,avl,v5,v6,
1/52
5) CXR – no cardiomegaly,
6) MEDICATION – T aspirin 300mg stat t plavix
VT BP 146/72 HR 65 SPo2 96% 300mg stat sc fondapurinox 2.5mg stat/od
U/L: RA, 99% on np dxt 8 lungs clear 7) Refer Medical
1. Hypertension 2. Diabetes no pedal oedema:
Mellitus 3. Dyslipidemia
TARIKH D: O/A: M/X: Tro Icb
4/5/2023 28/malay/female

MRN:
950123135378
C/O: O/E:
alleged sport injury on alert,consious pink good pv good
30/4/23 she slip and fell with hydrtaion crt<2sec warm 1) VITAL SIGN
head hit the floor post trauma pheriphery lung clear
claims had black vision but 2) ra
still able to hear surrounding 3) IVL + BTL
went to KKB and was refer 4) ECG – sr
VT :BP 142/87 PR 88 T 36.2
but pts did not come had 5) CXR – no cardiomegaly
headache this past 4/7 taken SPo2 98 under ra
Ct brain – no icb
migraine med but not resolved 6) MEDICATION –
had on and of blurring of
vision and nausea 7) Refer Medical

U/L:

TARIKH D: O/A: M/X: alleged dogbite category 3

4/5/2023 17/girl/indian 1) VITAL SIGN
2) ra
MRN: 3) IVL + BTL
060921102090 C/O: O/E: 4) ECG – sr
alleged dogbite 3/5/23 5.20pm alert, comfortable 5) CXR – no cardiomegaly
laceration wound left palm Wound irrigation and dressing
6) MEDICATION – iv cefuroxime/flagyl im att & voren
U/L: VT : 130/84 110 99 ra 20 36.3 stat
7) refer medical and hms
TARIKH D: O/A: M/X: AGE
4/5/2023 29 years old/female malay 1) VITAL SIGN
2)
MRN: 3) IVL + BTL
940308145522 C/O: O/E: 4) ECG – sr
1/ Vomit x 3/7 -more than 10 alert, GCS full, not tachypneic, 5) CXR
episodes in total -lsat vomit not tachycardic, warm 6) MEDICATION – IV Maxolon 10mg stat and TDS
5am today, mainly food peripheries, CRT< 2 secs, lips dry
content, no blood 2/ Diarrhea ORS per purge 1/1 TDS
x 3/7 -total more than 15 7) 1 pint ns bolus
episodes/day -last 8am today, 7) Refer Medical
no blood 3/ Fever x 1/7 -no VT : BP 115/64 PR 81 SpO2 98%
temp documented at home - under room air T 37
with chills and rigors -
resolved after took T PCM at
home yesterday around 9pm
4/ Reduce oral intake x 1/7

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