Nurul Atiqah Binti Mazlan, 12Y6M

previously well
ambulating well previously
NKMI
complaint of abdominal pain and
back pain for 9 months
sudden onset
denied any trauma event
on and off
generalised abdominal pain
radiated to the back for 9 months
sharp in nature
aggaravated by movement
otherwise
on and off fever
has LOA / LOW for the past 3
months
about 10kg in 2 months
no night sweats
no cough
no headache
no sob
also complaint of lethargy for the
past 2 months
PU and BO normal
patient went to Hospital Kajang in
March
evaluatiion done , noted abdominal
/ chest / pelvic x-ray done, advice
for ward admission for further
evaluation
however , not keen for admission
since then , patient went to parent's
hometown in Sabah
for alternative medicine - massage
and herbal medication

Examinaiton of the neck

ROM neck full
no cervical tenderness

complaint of bilateral knee pain for

almost 1 year
ADL dependent
required wheelchair for ambulation
currently
used to bed bound since this year
previously walk with walking frame
tolerated with analgesia

Examination of the back

tenderness over the thoracolumbar
and sacral region
no step defomity

On examination
alert
conscious
hydration fair

lymp node : cervical - Normal axillary - Normal

inguinal - Normal

Examination of Upper Limb

ROM shoulder / elbow / wrist full
no tender
sensation intact
CRT <2sec
power 5/5 and tone normal
Examinaiton of Left Lower Limb
ROM hip limited due to pain
reflex normal
sensation intact
power 5/5 and tone normal
Examination of Right Lower Limb
reduce sensation over the L3 - L5
power 5/5 - L2 - S1
tone normal
reflex normal
FBC : 7.3 / 24.7 / 1000 / 50
RP ;8.8 / 132 / 3.8 / 236
CHest x-ray
Pelvic x-ray
Thoracolumbar x-ray :

Lower limb examination

pain both knee
crepitus ++
muscle wasting both lower limbs
sensation intact
CRT <2sec
distal pulses palpable
knee x-ray : chronic bilateral knee OA
, ostepphyte++ , narrowing joint
space , subcondral sclerosis ++ /
subcondral cyst +
imp : chronic bilateral knee OA grade
4
Plan:
ketopatch
LMS cream
C. Tramadol 50mg TDS
T. PCM 1g QID
cont surgical plan

Plan:

after 9 months of alternative

medicine ,
condition not improve and patient
apparently had develop more
difficulty in ambulating
hence come to Hospital Serdang

On examination
alert
conscious
hydration fair
cachexic looking
pale
able to sit on the couch
lungs : clear
p/a:soft , tender , unable to
appreciate hepatosplenomegaly
cvs : drnm

On examination
Alert, concious
Pink
Warm peripheries
Good pulse volume
CRT< 2 sec
Temperature 37 ?? C
Pulse 90 /min
Respiration 21 /min
Systolic Blood Pressure 111
mmHg
Diastolic Blood Pressure 57
mmHg
SPO2 98 %
Respi: Fine crepts up to midzone
CVS: PSM at LSE and loud P2
PA: soft, non-tender, no ascites,
no hepatosplenomegaly
Left LL (dorsum of foot) :
clean
no foul smelling
granulation tissue
base was healthy
no pus d/c distal pulse palpable
confirm with doppler
sensation intact
crt <2sec
warm peripheries
able to move all toes

imp:chronic ulcer

PSx:
no hx of surgical intervention

Social Hx
1st child out of 4
went to school recently for UPSR
however , since March , on and off
went to school due to body
condition

Current issues:
(1) Community acquired
pneumonia, curb score 1 (respi
rate on presentation)
(2) MCTD with pulmonary
fibrosis
(3) Pyoderma gangrenosum

ABSI
left 1
right 1.33

PMhx:
denied any ward admission
no known drug and food alergy

Family Hx:
denied any family hx of cancer run
in the family
no blood disorder
no bone disorder

pain and minimal discharge

sserous , no pus discharge

LAMAH
refered for bilateral knee pain
Poor historian
History taken from family member
and maid
93 years old indian lady
Underlying :
1)Hypertension -bisoprolol 1.75mg
BD
2) CKD stage3
3)Bilateral knee OA with valgus
deformity-on c.tramal 50mg TDS and
t.pcm 1 g QID
Previously admitted in july for
pressure sore grade 1 at right lateral
thigh extending posteriorly and upto
right gluteus
ADL dependant
Bed bound since early this year due
to painful knee (bilateral
osteoarthritis)

refer for foot ulcer over left dorsum

58 years old Malay Lady
u/l
Mixed connective tissue disease with
pulmonary fibrosis
-SSA/SSB/RF positive. ANA 1:>2560,
speckeld
-HRCT done @ 24/12/13=pulmonary
fibrosis
-under rheumatology (last visit
11/9/14) : TCA 6/12 , off Prednisolone
-in view no active complaints of
fever/joint pain,cont her other meds
- ECHO as OP - ECHO on 16/1/2014
- To look for pulmonary arterial
pressure (loud P2)
HOPI
complaint of left foot ulcer for 4
months
initially size about 10 cent coin
progressively bigger in size
deneid any trauma / bite insect
dressing EOD at private clinic with
Aquacell Ag

plan
cont dressing with NS
cont abx
TCA 1 week ortho clinic after d/c

Skull: No fracture seen

16yo girl
underlying asthma on MDI PRN, no
history of intubation before
no known allergy to food/drug
c/o: alleged MVA and sustained
right lower limb pain
HOPI
Alleged MVA
Patient was riding motorbike and
then skidded
Unsure mechamism of injury
Post trauma: sustained right lower
limb pain and unable to ambulate
Patient also unable to move right
shoulder
Patient unable to recall event, LOC
?duration
Having bilateral nose bleed
Otherwise
no retrograde amnesia /
nausea/vomiting
no SOB
no chest pain
o/e
alert, conscious
GCS E4V5M6
not tachypneic, RR 18
not tachycardic, PR 80
bilateral pupils 3mm equal and
reactive
right maxilla swelling and abrasion
wound
no cervical tenderness, able to
flex/extend the neck
no paravertebral tenderness
chest spring negative
pelvic spring negative
lungs equal a/e
CVS DRNM
p/s soft and non tender
laceration wound over right index
finger about 0.5x1.0cm - no active
bleeding/exposed bone
examination of the right lower limb
minimal swelling and bruises over
the anterior of midshin
no wound seen
compartments soft
ROM of hip/knee and ankle unable
to assess due to pain at leg
unable to assess footdrop as
patient complain of pain
warm peripheries, CRT<2s
DPA, PTA palpable
sensation intact
examination of right upper limb
no swelling/bruises/wound
unable to move shoulder
ROM of elbow / wrist / fingers full
CRT<2s, warm peripheries
distal pulses palpable
sensation intact
Xrays of:
Right right tibia/fibula: comminuted
fracture midshaft of tibia
Femur: No fracture seen
Right knee: No fracture seen
Chest: No fracture seen

in ED,
FAST scan: -ve
sliding sign positive
IV morphine 3mg stat given
08/12/2014
COAGULATION SCREEN
13:22
Prothrombin
Time
14.5 sec (
11.614.7)
13:22
International
Normalised Ratio (INR)
1.12
13:22
Activated
Partial Thromboplastin Time
35.8 sec (
35.045.0)
13:22
APTT Ratio
1.2
Full Blood Count (FBC)
13:22
Haemoglobin
10.7 g/dL
Abnormal (
11.516.5)
13:22
Platelet 390
x10^9/L (150-400)
13:22
White Blood
Cells
14.0 x10^9/L ABNORMAL
(
4.011.0)
Renal Profile
13:22
Urea
3.4 mmol/L (
2.57.2)
13:22
Sodium 138
mmol/L (136-145)
13:22
Potassium
3.6 mmol/L (
3.55.1)
13:22
Chloride 109
mmol/L ABNORMAL (98-107)
13:22
Creatinine
61 umol/L (53-97)
IMP:
Alleged MVA and sustained
1)closed comminuted fracture right
tibia
2)cerebral concussion TRO ICB
Plan
awaiting surgical input
Xray - right shoulder - ordered, kindly
sent to radio
for backslab above knee over right LL
To bookdate ILN Right tibia
Watchout for compartment syndrome
circulation chart
Monitor vitals

Prem Narayan Baitha, 25Y

Nepalese
NKMI
previously well
occasional smokers
denied high risk behaviour
complaint of pain and bleeding over
the left hand
alleged assault by unknown male,
about 5 people
when to ATM machine to withdraw
money
assault by few men using knife
wanted to defend himself
one of the assaulter , hit his hand with
the knife
post trauma
sustain pain and bleeding over the left
hand
also pain and bleeding over the left
face
no other injuries
On examination
alert
conscious
hydration fair

Local examination of left hand

laceration wound at palmar aspect
over the ring and little fingers
at the PIP joint
measuring about 3x2cm
no bone exposed
?tendon cut
minimal bleeding
ring finger cannot flex
little finger able to flex
CRT <2sec
hand x-ray : no fracture
IMP : laceration wound at palmar
aspect over the ring and little fingers
with possible tendon cut
Plan :
keep patient in obay in view of no bed
currently
circulation chart
keep NBM at 4am with IVD 4 pint NS with alternate D5%
for Wound Debridement , Wound
Exploration and KIV tendon repair
under EMOT cm
start IV Cefuroxime 1.5g stat and
TDS
IM Tramadol 50mg TDS
FBC / GSH taken - to trace
for OTMS and consent in the ward