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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
On examination
alert
conscious
hydration fair
Plan:
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
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)
plan
cont dressing with NS
cont abx
TCA 1 week ortho clinic after d/c
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