EMJ PRESENTATION GROUP 8

NUURSYERIE ATIAH BINTI OSMAN 2014235018

YUSHASLIZA ANDREALYN BINTI YUSOF 2014239656
INTAN SYAHERAH BINTI MOHD ZAILANI 2014236926
NOOR NATASYA BINTI SARBINI 2014229094

SUPERVISOR : DR. MARK TAN

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 Patient’s demographic data
Patient’s Initial Mr. DS Chief complaint
Hospital CTC Mr. DS a 68 years old Indian man
Age 68 years old came to Emergency Department
Gender Male of CTC accompanied by his wife,
complaining of hemoptysis and
Race Indian
worsening shortness of breath
Date of Admission 11th January 2018 for 2 days.
Date of clerking 13th February 2018

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 History of presenting illness
D1 admission D2 admission
21st Dec 2017 9th Jan 2018 11th Jan 2018 12th Jan 2018

Elective PCI Hemoptysis Admission day Transferred to ICU

Due to anterolateral MI Dyspnoea PE : left lower zone
No intra procedure Orthopnoea Crepitations
complication Reduced effort tolerance Reduce air entry
Had pneumonia on D1 Fatigue Imp : acute pulmonary edema
post procedure Malaise Secondary to pneumonia
Discharged in 8th Jan Fever Tx : antibiotics
Sore throat
Runny nose Evening of admission day
Sx : dyspnoea worsened
PE : bilateral mid to lower zone
Crepitations
Reduce air entry
Tx : intubated & ventilated in
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CCU
 D4 admission D8 admission D34 admission D35 admission
14th Jan 2018 18th Jan 2018 14th Feb 2018 15th Feb 2018

Extubated Reintubated after Patient was concious & Tracheostomy was done
developing respiratory alert Ventilator off
failure type 1 secondary GCS : VT, motor 6, eye 4
to aspiration Planned for
pneumonia tracheostomy
His wife consented

D49 admission D57 admission D58 admission

1st Mar 2018 8th Mar 2018 9th March 2018

Transferred to ward Patient’s condition worsened Patient went into Patient was pronounced
SpO2 dropped to 60% cardiac arrest dead at 1.30 am
Continuos suction and CPR was done
bagging

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 Past medical & surgical history

 Hypertension, Diabetes Mellitus and dyslipidemia diagnosed for 20 years

 Ischemic heart disease and chronic kidney disease stage 3A diagnosed in
April 2017
 There was no history of hospital admission for hypertensive emergency,
stroke, hyperglycemic or hypoglycemic emergency
 Has blood pressure and blood sugar monitoring at home, unsure of latest
HbA1c
 No past surgical history

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 Drug and allergy history

 Mr. DS was allergic to seafood where he develop itchiness when consume.

 He took :
1. Tab Frusemide 40mg OD
2. SC Actrapid 14/12/12
3. SC Insulatard 16 U ON
4. Tab Captopril 35mg BD
5. Tab Atovastatin 40mg ON
6. Tab Ticagrelor 90mg BD
7. Tab Aspirin 75mg OD
8. Tab Bisoprolol 10mg OD
9. Tab Pantoprazole 40mg OD

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 Social history

 He lived with his wife in a terrace house in Kota Damansara, Selangor with
good basic amenities. His wife was the sole caretaker.
 He had 3 children. He was a pensioner of whereas his wife is a housewife.
He never smoked and only drink alcohol occasionally about a few times in a
month.

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 Family history
significant 1st degree family
history (mother and father) of
hypertension and Diabetes
Mellitus

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 Physical examination

 General examination
Mr. DS was lying in the bed with one pillow 45 degree propped up. He appeared pale
and weak. However, he was conscious and alert to time, place and person. He was
not in pain nor was he in respiratory distress. GCS score : Eye 3 Verbal T Motor 6.
He was intubated with endotracheal tube which was connected to the
ventilator. There was an IV branula on the dorsal aspect of his right hand connected
to normal saline. There was a central venous catheter inserted at the right internal
jugular vein and Ryle’s tube inserted through the nasal cavity for feeding. There was
also a continuous bladder catheter insertion draining yellow coloured urine. Airway
secretions were moderate in volume, whitish in colour and thick in consistency.

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 Vital sign
 Blood pressure :81/49mmHg
 Temperature :37.6°C
 Pulse/AB :100 bpm with regular rhythm and good volume
 SPO2 :100% on ventilation
 Respiration :24 bpm
 Pain Score :unable to assess
Impression – he was hypotensive

 Hydration status
Hydration status was fair. The skin turgor was normal but the lips were dry
and chapped, no sunken eyes, capillary refill time <2seconds, urine output
20-50ml/hour - normal, warm extremities.
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 Examination of face, head and limbs

Face No dysmorphic appearance

Eyes There was pallor of conjunctiva, no icterus
Oral cavity Oral hygiene was bad, coated tongue, dry and
chapped lips
Neck No neck swelling
Hands There was palmar pallor but no peripheral cyanosis
Lower limbs Edema of both limbs up to the knees
Skin No rashes, petechia or ecchymosis

Impression – he was anemic and dehydrated

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  Examination of the back
Unable to perform.

 Examination of lymph nodes

Unable to perform.

 Central Nervous System Examination

Higher function status: He was alert and and conscious.
Cranial nerves: Unable to perform.
Motor function of both upper limb: Unable to perform.
Sensory function of both upper limb: Unable to perform.
Sign of meningeal irritation: Unable to perform.
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 Abdominal Examination

Inspection The abdomen was not distended and moved with respiration.
The umbilicus was centrally located and inverted. There was no
surgical scar, no dilated vein, no visible peristalsis/pulsation and
no caput medusa noted.
Palpation Unable to perform.
Percussion Unable to perform.
Auscultation Unable to perform.

Interpretation : Unable to interpret because unable to complete the examination.

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 Respiratory Examination

Inspection There was endotracheal tube connected to ventilator. There

was no structural deformities, no symmetrical movement of
chest wall with respiration, no recession and no scar noted.
Palpation The chest expansion was symmetrical bilaterally.
Percussion Resonant on both sides.
Auscultation Air entry equal bilaterally. No added sounds. Lungs clear.

Interpretation : Unable to interpret because unable to complete the examination.

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 Cardiovascular Examination

Inspection There were no surgical scar, no superficial dilated vein, no skin

discoloration, no visible pulsation and no pericardial bulge.
Palpation Apex beat was palpable at the 4th intercostal space at the
midclavicular line. No heave and thrills.
Percussion Not perfomed.
Auscultation Dual rhythm heard and no added sound.

Interpretation : Unable to interpret because unable to complete the examination.

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 Clinical Summary

 Mr. DS a 68-year old Indian man came to Emergency Department of CTC

accompanied by wife, complaining of hemoptysis with worsening shortness
of breath for 2 days.
 On physical examination, he is intubated and ventilated. Respiratory
examination revealed air entry was equal bilaterally. No added sounds.
 On the day of clerking, the patient was a febrile, not in pain, nor in
respiratory distress, tolerate feeding well with Ryle’s tube and good urine
output, as observed in the charting sheet.

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 INVESTIGATION

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  Full Blood Count (6th March 2018)
Normal readings Results
Haemoglobin level (g/dL) 12.0 - 15.5 9.4
White blood cell count 4.5 - 11.0 13.8
(x10^9/L)
Platelet (x10^9/L) 150 - 400 319

Impression : The patient was anemic and there was infection going on.

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  Blood Urea and Serum electrolyte (6th March 2018)
Normal readings Results
Urea (mmol/L) 2.5 - 8.0 27.6
Sodium (mmol/L) 135 - 145 152
Potassium (mmol/L) 3.6 - 5.2 3.2
Creatinine (mmol/L) 45.0 - 90.0 245

Impression : Chronic Kidney Disease Stage 4

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  Tracheal Aspirate Culture and Sensitivity
Date Results
17/1/2018 MRSA Sensitive to vancomycin
20/1/2018 MRSA Sensitive to vancomycin
9/2/2018 Mixed growth 3 Types
19/2/2018 Mixed growth 3 Types
22/2/2018 Staphylococcus Aureus
27/2/2018 MRSA

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  Blood Culture and Sensitivity
Date Results
11/1/2018 No growth
19/1/2018 Vancomycin Resistant Enterococcus (VRE)
Resistance toward Ampicillin.Penicillin
23/1/2018 Anaerobe
Resistance toward cloxacillin
Sensitive with vancomycin
27/1/2018 Gram negative bacilli
1/2/2018 Klebsiella Pneumoniae
6/2/2018 No growth
9/2/2018 No growth
18/2/2018 No growth
22/2/2018 No growth

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  Urine Culture and Sensitivity

Date Results

9/2/2018 No growth

22/2/2018 No growth

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  Chest xray (16th February 2018)
 Indications : post tracheostomy

Results:
i. Clear lung field
ii. Tracheal tube in situ above the manubrium
iii. No significant finding

Impression : confirmation of tracheal tube positioning.

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  CT Thorax (11th January 2018)
 Indications : Hemoptysis and respiratory failure

Results:
i. The pulmonary trunk, left and right main pulmonary arteries and its branches are
patent with no filing defect.
ii. Bilateral lung consolidation in perihilar and dependant segment distribution. Ground
glass changes are seen in both lungs.
iii. No nodules in the aerated lungs.
iv. Bilateral pleural efusion (R>L)
v. An enlarged lymph node is seen at 4R station measuring 1.2cm
vi. Cardiomegaly
vii. Degeneratives changes of the bones. No suspicious bone lesion

Impression : Features are compatible with cardiogenic pulmonary oedema.

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 DISCUSSION
• CONSENT
• DOCUMENTATION

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 Introduction

 In this section, we would like to highlight 2 significant ethical issues that we

were able to observe and discuss in depth in regards to the patient and
patient’s management throughout his stay in UiTM Clinical Training Centre.
The 2 matters include:
 Patient’s consent

 Documentation of patient’s daily progress

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 CONSENT

 Consent can be defined as “the voluntary acquiescence by a person to the

proposal of another, the act of or result of reaching an accord, a
concurrence of minds; actual willingness that an act or an infringement of
an interest shall occur.” (Malaysian Medical Council Guideline on Consent
for Treatment of patients by Registered Medical Practitioners (2016))

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  In the case of this patient, a consent was required from Mr Devados when he was
indicated for a tracheostomy due to prolonged intubation.

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  Hence, it is crucial that a medical officer or practitioner discloses
important information regarding the said procedure to the patient,
ensuring that the patient is well-informed and thoroughly
enlightened on the benefits as well as the risks of the any proposed
procedures for that matter.

Reference: Malaysian Medical Council Guideline on Consent for Treatment of patients by Registered Medical Practitioners (2016)

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  The patient’s family, including his wife and his daughter (accompanied by a close
family friend) was brought in to discuss the tracheostomy procedure that was
planned for Mr Devados due to prolonged intubation.

 The patient was not able to make his own decision and to give consent because
he was in an altered consciousness state and was unable to make a reliable
decision on his own.

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  The patient’s family members (wife and daughter) discussed with the involving
otorhinolaryngology surgeon on the following matters before the consent was
signed:
 the nature of the procedure

 how it was going to be carried out

 the mode of anaesthesia that the procedure required

 the duration of the procedure

 where the procedure was going to be held

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  Other contents of the discussion include:
 The surgeon also successfully able to show visual examples of the procedure from
pictures on her computer.

 She explained the basic anatomy of the airway and oesophagus.

 She also described in depth, the possible risks and complications from the execution
of the procedure.

 The surgeon discussed thoroughly and comprehensively with the family the post-
operative care that he would have needed.

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  From our first-hand observation of this event, the surgeon successfully
accomplished a good medical practice because:
 She was the one who obtained the consent and was responsible to disclose important
knowledge to the patient/patient’s family.

 She explained the needs and requirements of the indicated procedure.

 She briefly educated the family on the basic anatomy of the neck in which may be
important for the family members to know.

 She made sure to answer all questions and concerns from the patient’s family.

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 MEDICAL RECORD

 Medical record can be defined as; “documented information about the

health of an identifiable individual recorded by a practitioner or other
healthcare professional, either personally or at his or her instructions.”
(Malaysian Medical Council Guideline on Medical Records and Medical
Reports (2006))

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 Contents of a patient’s medical record:

 Doctor’s clinical notes – All clinical notes were handwritten.

 Recording of discussion with patient /next of kin regards

disease/management (with witness) – Handwritten documentation
(Discussion with family members regarding tracheostomy procedure)

 Laboratory & Histopathological reports – The reports were documented.

 Imaging records and reports – The reports were documented.

 Drug Prescriptions – All the drugs prescribed were documented.

Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
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  Nurses’ Reports – All the nurses’ reports were handwritten.

 Consent Forms – The forms were documented.

 Operation Notes/Anaesthetic Notes – Printed and handwritten notes were

documented.

 Printouts from monitoring equipment (e.g. Electro-cardiogram) –

Printouts from ECG were kept.

 Computerized/electronic records
Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
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  Clinical Photographs

 At-Own-Risk Discharge Forms

 Video Recordings

 Letters to and from other health professionals

 Recordings of telephone consultations/instructions relevant to the care of the patient

Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)

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 Integrated Clinical Notes

 Healthcare personnel that were involved: medical team,

otorhinolaryngology team, anesthesiology team, physiotherapist, dietitian
and staff nurses, they made their entries according to the guideline.
 Use of abbreviations and short forms should be avoided

 Some examples of abbreviations and short forms used in Mr. DS’s medical
records: RTF (Ryle’s tube feeding), TM (tracheostomy mask), norad
(noradrenaline), pt (patient), temp (temperature), rt (right), exs (exercise).

Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
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  Entries should be avoided

 In Mr. DS’s clinical notes, noted to have blank spaces in between the
entries.
 Correction to notes

 Mr. DS’s medical records, some entries were crossed out nicely but no
sign, and some entries were crossed out and not readable.

Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)

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 MEDICAL REPORT
 Medical Reports are documents prepared by a practitioner on a patient based on
Medical Records. (Malaysian Medical Council Guideline on Medical Records and Medical
Reports (2006))

 Complete Medical Reports must be provided by the doctors when requested by patients
or by the next-of-kin, in the case of children and minors, or by the employer with the
patient's consent. Any refusal or undue delay in providing such reports is unethical.
(Malaysian Medical Council Guideline on Good Medical Practice (2001))

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 Contents of patient’s medical report:

 Patient identification data

 Dates and time of admission or treatment

 Brief history

 Significant examination findings

 Results of relevant investigations

 Diagnosis

 Treatment

 Management plan
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Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
 REFERENCES

 Medical Records and Medical Reports. (2006). Malaysian Medical Council,

pp. 6-23.
 Consent for Treatment of Patients By Registered Medical Practitioners.
(2016). Malaysian Medical Council, pp. 1-13.
 Good Medical Practice. (2001). Malaysian Medical Council, pp. 1-18.
 Hope, R. A., Savulescu, J., & Hendrick, J. (2016). Medical ethics and law: The
core curriculum. Edinburgh: Churchill Livingstone Elsevier.

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 THANK YOU

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