Audit

1st Dec 2010

• IAL , 43 / Iban /Female
• Address: Rh Takin Pasai Bon
• Date of Admission : 21/11/2010
• Time : 0755 hrs
• Chief complaint of : Giddiness, on wheelchair
• Triage category : G1
 Seen by AMO
• 0804 hrs
• Giddiness x 3 days,fever x3 days
• Neckache,retrosternum pain.loose stool,gen body
weakness
• No SOB,
• O/E – weak on wheelchair
• BP 120/70mmHg , PR 89 T 36.9 C
• GCS 15/15 , spo2 100%
• Plan – FBC,BUSE ,BFMP and for MO review
 Seen by HO
• 0900 hrs
• History of fever with chills and rigors since
19/11/2010.
• Diarhoea since yesterday, reduce oral intake.
• Assoc with headache,myalgia,arthralgia.
• Took PCM 6.00 am today
• Denied any SOB,skin rashes ,bleeding
tendency/vomiting/abd pain.
• No history of fogging,dengue ill contact.
• PMH –known HPT and DM on treatment.
• Pink , hydration good.
• CVS DNM, lung equal air entry.
• Abdomen soft , non tender and no
organomegally, no pedal edema.
• CRT < 2 sec. HGT 16.6 mmol/L
• Hess test positive.
• Body weight 80 kg.
• Plan :
– ECG Sinus rhythm,no ischemic changes
– T.stemetil 2 tab stat.
– Sc actrapid 4u stat. 0930 hrs.
– UFEME,ABG.
– Patient kept at waiting area .
• Investigation result
– FBC – 13.0/2800/27,000/36%
– BUSE- 131/4.4/96/12.4
– BFMP- negative
– ABG- pH 7.398,po2 95.3 , pCO2 22.9 , BE
-9.2,HCO3 17.0
– UFEME-ketone negative
 progress
• Pt complaint of epigastric pain at 12.15 noon
• Given IV Ranitidine 50 mg stat.
• Case referred to Medical MO oncall
• Assessment given as
– AGE with mild renal impairment
• Plan – Admit Female Medical Ward
– For CXR on way up.
– For IV Drip,
– PT/PTT,LFT,GSH,Creat.
• SN FMW informed at 1215 hrs.
• THANK YOU