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© EMJ 2018 1
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
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
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
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Drug and allergy history
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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
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.
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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
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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
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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
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Introduction
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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
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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 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 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
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Contents of a patient’s medical record:
documented.
Computerized/electronic records
Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
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Clinical Photographs
Video Recordings
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Integrated Clinical Notes
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:
Brief history
Diagnosis
Treatment
Management plan
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Reference: Malaysian Medical Council Guideline on Medical Records and Medical Reports (2006)
REFERENCES
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THANK YOU
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