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Result Type: General Clerking Note

Result Date: 15 July 2018 13:11


Result Status: Auth (Verified)
Result Title: GENERAL CLERKING BY IMHO FATIMAH.Z
Performed By: Dr Loh Ai Yun , Int Med MO on 20 July 2018 22:57
Verified By: Dr Loh Ai Yun , Int Med MO on 22 July 2018 08:14
Encounter info: 2018-0287235, HSI, IP 3rd Class, 15/07/2018 - 18/07/2018

General Clerking Note

Location :

<General Clerking by IMHO Fatimah Zahra>

S/B Dr.Loh AY, later seen by Dr Tay ME at 3pm

32 years old Malay Gentleman


NKMI,NKDA
BW 51kg
Active smoker for past 15years
-15 sticks per day

C/O:
Referred from KK Ulu Tiram TRO Leptospirosis

HOPI:
Patient was apparently well claim started until last friday

Fever x 3days ago


-on Friday(13/7) at around 11pm
-claim sudden onset,on and off
-a/w chills and rigor,resolved with PCM,claim took 2pils,last taken at 6.30am today
-claim took temperature yesterday night,40.5'c

Lethargy
-claim was been feeling more tired and weak since Friday
-+myalgia and arthalgia

Claim feeling nauseated since today morning

History of rodent contact


+Noted rats in house for the past one week,unsure regarding contact.

On further history noted patient has been feeling unwell and lethargy for the
past one week.However fever only started 3days ago.Patient claim went to Dentist one week
ago,informed
BP low,advice to go hospital,however patient did not seek medical attention.

Otherwise
no rashes,no retroorbital pain
no gum bleeding,no mucosal bleeding
no abdominal pain,no vomitting,no diarrhea,no abdominal distension
no chest pain,no sob
no headache,no dizziness
no fainting episodes
no UTI ssx
no cough/URTI ssx

Patient went to KK Ulu Tiram today noted BP 56/26,after repeated BP 67/28>>run fast one
pint NS>>BP 86/49,PR 50,T 37.8,SPO2 99% under RA.Otherwise lung clear,cvs drnm,pa
snt.Patient referred to EDHSI for further management
In EDRZ noted BP 90/53 PR 70 ,T 38.3,started IV Gela Bolus
5cc/kg/hr(250cc/hr)@1300H,IV Noradrenaline running at 0.05mcg/kg/min.
Family and Social history:
Patient married,blessed with 3children.Currently staying with wife and childrens in Ulu
Tiram.Working as a technician in Desa Cemerlang.Active smoker for the past 15
years,around 15sticks per day.Denies alcohol intake,IVDU and high risk behaviour.No
family history of DM,HTN and malignancy.No history of dengue in family and
neighbours.Denies any recent fogging and dengue incident in housing area and working
place.No history of recent travelling
O/E
Alert
Conscious
Lethargy+
Clinically pink
Hydration fair
CRT<2sec
On going IVD 3cc bolus@14.30H

VS
BP 104/59 on ivi noradrenaline 0.05mcg/kg/min
PR 69bpm
SPO2 98% under RA
T 38.3'C
GM 6.9

CBD 300cc,concentrated urin since admission at 1220H

Lungs fairly clear


CVS DRNM
PA tender at right hypochondrium and epigastric region,liver palpable 2FB

Ix
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin
Wbc 9.17 7.8 6.6
Hb 14.7 12.1 12.7
Plt 117 75 106
Hct 41.4 34.4

UFEME
Leu -ve
Nit -ve
RBC 1+
Ketone 1+

VBG post 5cc bolus gelafundin


ph 7.46 7.43 7.52
pco2 32 34 26.7
hco3 22.8 22.6 21.2

RP
Na 136
K 3.9
Ur 6.8
Cr 90
Dengue serology 15/7
IgM -ve
IgG -ve
NS1 antigen -ve

ECG SR, no acute ischaemic changes

CXR Clear

Impression:
Septic shock 2' TRO Leptospirosis

Plan
Admit ward 7A(acute cubicle)

VS monitoring
Strict I/O Charting
Titre IVI Norad accordingly
-Keep MAP > 65

Start IV Ceftriaxone 2g stat and OD


IV Maxolon 10mg TDS
IV Ranitidine 50mg TDS
IVD 5pint NS/24hours

Send Septic workout(Blood C+S,Urine C+S), urine feme, CRP


BFMP stat and x 3
FBC,RP,LFT,AST,CRP,CK,Coagulation profile cm
viral screening cm-patient consented verbally

Trace leptospirosis serology


Result Type: Doctor Progress Note
Result Date: 18 July 2018 10:24
Result Status: Modified
Result Title: IM AM SP/MO review
Performed By: Siti Muslihah Binti Anuar , ANHO on 18 July 2018 13:25
Verified By: Siti Muslihah Binti Anuar , ANHO on 18 July 2018 13:51
Encounter info: 2018-0287235, HSI, IP 3rd Class, 15/07/2018 - 18/07/2018

* Final Report *
Document Contains Addenda
Patient Progress Note (Doctor)

Location :7A

seen by Dr Hashvina and Dr Nazri


32 years old Malay Gentleman
NKMI,NKDA
BW 51kg
Active smoker for past 15years
-15 sticks per day

Impression:
Septic shock TRO Leptospirosis
C/O:
Referred from KK Ulu Tiram TRO Leptospirosis

HOPI:
Patient was apparently well claim started until last friday
Fever
-started 3days ago
-on Friday (13/7) at around 11pm
-claim sudden onset,on and off
-a/w chills and rigor,resolved with PCM,claim took 2pils,last taken at 6.30am
today
-claim took temperature yesterday night,40.5'c

Lethargy
-claim was been feeling more tired and weak since fri
-+myalgia and arthalgia
Claim feeling nauseated since today morning

History of rodent contact


+Noted rats in house for the past one week,unsure regarding contact.

Otherwise
no rashes,no retroorbital pain
no gum bleeding,no mucosal bleeding
no abdominal pain,no vomitting,no diarrhea,no abdominal distension
no chest pain,no sob
no headache,no dizziness
no fainting episodes
no UTI ssx
no cough/URTI ssx

Patient went to KK Ulu Tiram today noted BP 56/26,after repeated BP 67/28>>run


fast one pint NS>>BP 86/49,PR 50,T 37.8,SPO2 99% under RA.Otherwise lung
clear,cvs drnm,pa snt.Patient referred to EDHSI for further management
In EDRZ noted BP 90/53 PR 70 ,T 38.3,started IV Gela Bolus
5cc/kg/hr(250cc/hr)@1300H,IV Noradrenaline running at 0.05mcg/kg/min.

On further history noted patient has been feeling unwell and lethargy for the
past one week.However fever only started 3days ago.Patient claim went to Dentist
one week ago,informed
BP low,advice to go hospital,however patient did not seek medical attention.

Family and Social history:


Patient married,blessed with 3children.Currently staying with wife and childrens
in Ulu Tiram.Working as a technician in Desa Cemerlang.Active smoker for the
past 15 years,around 15sticks per day.Denies alcohol intake,IVDU and high risk
behaviour.No family history of DM,HTN and malignancy.No history of dengue in
family and neighbours.Denies any recent fogging and dengue incident in housing
area and working place.No history of recent travelling
Progression
Comfortable under RA
No desaturation, not tachypneic

just wean off IVi Norad this morning


latest BP 104/62mmHg, unsupported

Afebrile
on IV Ceftriaxone 2g OD -D4

Tolerating orally well


No vomiting
No diarrhea

O/E
Alert, conscious
Clinically pink
Hydration good
Good pulse volume
CRT<2sec

VS
BP 104/62mmHg, unsupported
PR 70bpm
T 37.0'C
SpO2 97% under RA

Lungsclear
CVS DRNM
PA liver palpable 2FB

Investigation:
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin 16/7 17/7
Wbc 9.17 7.8 6.6 10.7 8.0
Hb 14.7 12.1 12.7 13.9 12.3
Plt 117 75 106 137 106
Hct 41.4 34.4 40.2 34.5

UFEME 15/7
Leu -ve
Nit -ve
RBC 1+
Ketone 1+

VBG post 5cc bolus gelafundin


ph 7.46 7.43 7.52
pco2 32 34 26.7
hco3 22.8 22.6 21.2

RP 15/7 16/7
Na 136 137
K 3.9 3.3
Ur 6.8 5.3
Cr 90 77

LFT 15/7 16/7 17/7 18/7


TB 32.9 21.9 12.1 9.8
TP 80 78 73 73
Alb 43 39 35 35
ALT 16 14 13 11
ALP 72 74 66 90

Dengue serology 15/7


IgM -ve
IgG -ve
NS1 antigen -ve

Blood culture (15/7) : NG D2

BFMP x 3 - No malaria parasite seen

Viral screening : NR

ECG SR, no acute ischaemic changes

CXR Clear

Plan
VS monitoring hourly
Keep MAP>65
Keep SpO2>95%
Strict I/O Charting
Off CBD -patient requested. For patient self-charting IO
Off IVD

Send LFT, AST daily


ESR in next blood taking

Trace TFT, Leptospirosis serology


Blood C+S

Off IV Ceftriaxone 2g OD
Start IV Cloxacillin 500mg Q4H

Cont IV ranitidine 50mg TDS


IV maxolon 10mg TDS

for ECHO in-patient --TRO IE

If patient develop temp spike, for USG abdomen

Addendum by Siti Muslihah Binti Anuar , ANHO on 18 July 2018 16:43

Patient keen for discharge

Dr Nazri explained regarding risk of syncope/severe sepsis/death/septic shock if refuse antibiotic/medical


treatment.
Patient understood, and still keen for discharge

Plan:
allow AOR discharge
TCA IMC 2 weeks

Discharge with:
T Cloxacillin 500mg QID x 1 week

Addendum by Siti Muslihah Binti Anuar , ANHO on 18 July 2018 16:59


Plan above was d/w Dr Hashvina

TCA IMC 1 month with ECHO and to review TFT result


Result Type: Discharge Summary
Result Date: 18 July 2018 18:12
Result Status: Transcribed
Result Title: Discharge summary by IMHO Siti Muslihah
Performed By: Dr Nazri bin Ab. Kahar , Int Med MO on 18 July 2018 18:36
Encounter info: 2018-0287235, HSI, IP 3rd Class, 15/07/2018 - 18/07/2018

* Preliminary Report *
Discharge Summary

DOA: 15-July-2018
DOD: 18-July-2018

ICD-10: R65.21

Final Diagnosis:
Septic shock TRO Leptospirosis

32 years old, Malay Gentleman


NKMI, NKDA
BW 51kg
Active smoker for past 15years
-15 sticks per day

Case summary:
This 32 years old gentleman, presented with history of fever for 3days, associated
with lethargy, myalgia, arthralgia and nausea. Intially went to KK Ulu Tiram,
patinet noted to be hypotensive. Thus, referred to HSI for further management. In
ED, noted persistantly hypotensive despite fluid resuscitation, hence started on
inotropic support, with maximum requirement 0.3mcg/kg/hour. Able to weaned off
IVi Noradrenaline this morning, ranging BP 95-110/57-68mmHg with MAP >65.
Otherwise, patient well, tolerating orally, no other active issue. However, patient
keen for AOR discharge today.

Dr Nazri explained regarding risk of syncope/severe sepsis/death/septic shock if


refuse antibiotic/medical treatment. Patient understood, and still keen for AOR
discharge.

Examination prior to discharge:


Alert, conscious
Clinically pink
Hydration good
Good pulse volume
CRT<2sec

VS
BP 99/57mmHg, unsupported
PR 72bpm
T 36.8'C
SpO2 96% under RA

Lungsclear
CVS DRNM
PA liver palpable 2FB

Investigations:
FBC KK Ulu Tiram Minilab post 5cc bolus gelafundin 16/7 17/7
Wbc 9.17 7.8 6.6 10.7 8.0
Hb 14.7 12.1 12.7 13.9 12.3
Plt 117 75 106 137 106
Hct 41.4 34.4 40.2 34.5

UFEME 15/7
Leu -ve
Nit -ve
RBC 1+
Ketone 1+

VBG post 5cc bolus gelafundin


ph 7.46 7.43 7.52
pco2 32 34 26.7
hco3 22.8 22.6 21.2

RP 15/7 16/7
Na 136 137
K 3.9 3.3
Ur 6.8 5.3
Cr 90 77

LFT 15/7 16/7 17/7 18/7


TB 32.9 21.9 12.1 9.8
TP 80 78 73 73
Alb 43 39 35 35
ALT 16 14 13 11
ALP 72 74 66 90

Dengue serology 15/7


IgM -ve
IgG -ve
NS1 antigen -ve

Blood culture (15/7) : NG D2

BFMP x 3 - No malaria parasite seen

Viral screening : NR

ECG SR, no acute ischaemic changes

CXR Clear

Discharge plan:
Allow AOR discharge
TCA IMC 1 month with ECHO and to review TFT result

Discharge with:
T Cloxacillin 500mg QID x 1 week