Note Type

: Ambulance Call
Form

Med/Anc
: Emergency
Service
: Nik Khairul Rusydi b
Performed By
Kamaruzam

Date/Tim
: 31/08/2013 07:54
e

Ambulance Call Form

Part 1 Call Information (To be filled by Call Taker)
Call Card No.
Tarikh
Masa Panggilan Diterima
AMO Yang Terima Panggilan
Nama Pemanggil
Nombor Telefon
Alamat/Lokasi Kejadian
Butiran kes-kes MVA
Bilangan mangsa
Jenis kes
Aduan
Masa Bertolak

:
:
:
:
:
:
:
:
:
:
:
:

6871
31/08/2013 04:08
31/08/2013 04:08
Faizal
Shahrul
0166567728
(PLUS) LBR UTARA SELATAN
Passenger
4org
Trauma
Alleged MVA
31/08/2013 04:09

Part 2 Assessment on Scene

Masa Tiba Di Lokasi
: 31/08/2013 05:06
Assessment on Scene
Date/Time
Conscious Level Airway Obstruction
31/08/2013 05:07
A
No
Assessment on Scene
B.P
Pulse
106/72
127

SaO2
87

Color
Normal

Part 3 Initial Resuscitation and Treatment

Oxygen
Suction
Oropharyngeal Airway
Intubation
Nebulizer
ECG Monitoring
Pressure Dressing
Cervical Collar
Spinal Board
Limb Immobilization
Defib
CPR
Masa Bertolak Dari Lokasi
Masa Ketibaan Di Hospital
Laporan Ringkas

:
:
:
:
:
:
:
:
:
:
:
:
:
:
:

15L/min
No
No
No
No
No
No
Yes
Yes
No
No
No
31/08/2013 05:15
31/08/2013 05:51
c/o : alleged MVA
~ on arrival pt still in car

Breathing
Yes

~
~
~
~
~
~
~
~
~

fireman team clear danger and bring pt to safe area

team ambulance approaching pt at safe area
pt alert and concious
no LOC, no vomiting, no ENT bleeding
unable to walk and talk in full sentences
GCS : 15/15 ( E4 V5 M6)
pt complain sob and chest pain at right sided
auscaltation air entry reducing at right sided lung
chest rise not bilateral equal

Cervical collar and spinal board applied

HFM 15l/m applied
===> Pt triage to resus

Pasukan Ambulan
Penolong Pegawai Perubatan:
Pemandu
:
No. Ambulan
:

Khairul
Khairudin
WMP 7401

Note Type : ED Clerking

Date/Tim : 31/08/2013
e
08:41

Med/Anc Service : Emergency

Performed By : Vinotheran A/L P.manogram,DR

ED Clerking
Complaint, History and Findings
Complaint, History & Findings :

Triage to Red zone:

-suspected Pneumothorax
patient was one of the victims in a carcar crash into a huge drain
upon arrival
GCS full
pale
pulse 136
BP 74/52
spo2 under HFM oxygen 15L/min
complaints of sob / difficulty in breathing
chest pain over right side
no other active complaints
o/e:
primary survey :
airway :
speak in full sentences
on cervical collar
trachea central

breathing :
right side of chest :
reduce movement
subcutaneos emphysema present
hyperresonant on percussion
-inserted 2 chest tubes
size 24 and 32 fr
-in view of SPo2 and blood pressure persistently low
and chest remain hyperresonant
chest tube inserted -> drained 700ml fresh blood
patient not improved with initial chest tube -> second
chest tube inserted on right side
- drained 300ml, clamped as total volume drained is 1L
over less than one hour

circulation :
poor pulse volume , tachycardic
crt< 2sec
bp 74/52
Total fluid resuscitation :4 pint pack cell / 3 pint colloid
- noted developed urticaria
-given iv piriton 10mg stat / iv hydrocortisone 200mg
stat
abdomen soft nontender
bowel sound present
pelvic spring negative
disability :
gcs full
pupils equal reactive 3mm/3mm bilaterally
exposed adequately
ABG on arrival -> pH 7.296, pCO2 41.8, pO2 65.8,
HCO3 19.5, BE -5.6, Lac 6.6
Mx:
Intubated for airway protection - as spo2 78 % under
hfm / hypotensive
IVI midamorphine 3 ml/hour
strict i/o charting
cbd insertion
IV morphine 6mg in total given
IV tranexemic acid 1g stat and 1g over 8 hours
warmer
case is attended by anaesthesiology and surgical team

***case explained to brother in law- Mr. Hasbah

**allergic reaction to safe O blood bank mo Dr. Anis -mentioned has 2 more pint pc available- gxm code
3112
-if patient proceeds with surgical intervention in OT - 6
pints GSH available - code 3101 right

Management and Progress

Note Type : GS Ward Progress Notes

Date/Time : 31/08/2013 07:31

Med/Anc Service : Emergency

Performed By : Chua Li Shun,Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Summoned Visit
Dr Chua LS

Complaint(s) and Progress

Complaints, If Any

39/M
alleged MVA at ?time ?place
found by roadside
sent via ambulance call
history from A&E MO
on arrival GCS full
laboured breathing
noted reduced chest movement with poor oxygen
saturation 78-80% on HFM
hypotensive, tachycardic
intubated for respiratory distress
on assessment patient is intubated, sedated
pale
SPO2 100%
BP 64/43, tachycardic 120/min
weak pulse volume
lungs reduced air entry bilaterally worse over right side
hyperresonat bilaterally
+subcutaneous emphysema
p/a guarded over umbilical region
CBD inserted -> clear urine
no other obvious injuries
no bruises

no imaging done yet

clinically suggestive of right haemopneumothorax
right chest tube inserted -> drained 700ml fresh blood
patient not improved with initial chest tube -> second
chest tube inserted on right side
- drained 300ml, clamped as total volume drained is 1L
over less than one hour
resuscitated with 3 pints PC so far
ABG on arrival -> pH 7.296, pCO2 41.8, pO2 65.8, HCO3
19.5, BE -5.6, Lac 6.6
Progress Since Last Review :

reviewed patient with Miss Zeti

- currently patient's BP 100-110/70-80 mmHg
- tachycardic 120/min
- resuscitated with 4 pints PC so far
- hyperresonant over right lung
- abdomen guarded at umbilical region

Treatment
Laboratory Investigation

New Orders / Mx Changes

Hb 14
WBC 15
Plt 400
IMP:
1. Severe chest injury with massive right haemothorax
2. TRO intraabdominal injury
Plan
1. for urgent CT thorax and abdomen KIV CTA, trace
urgently
2. trace X-rays urgently
3. continue blood transfusion and DIVC regime
4. continue resuscitation
5. for thoracotomy KIV exploratory laparotomy if indicated

Authorship and Healthcare Provider List

Medical Officer
Specialist

:
:

Dr Chua LS
Miss Zeti Karim

Addendum Created By: Chua Li Shun,Dr, Date/Time: 31/08/2013 07:55:25

s/t Dr Jarrod (MO Radiology on call)

- he will discuss with the radiologist and call us back

Note Type

: GS Ward Progress
Notes

Date/Tim
: 31/08/2013 13:55
e

GS Ward Progress Notes

Med/Anc
: Anaesthesiology
Service
: Nurul Aimi binti Abd
Performed By
Ghani,DR

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Ms Safa and Dr Deva

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 (car crushed into the drain)

Issues :
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
- 2 chest tubes inserted in ED, 1st chest tube inserted,
drained 400cc blood, 2nd chest tube inserted, drained
50cc of blood (minus 300cc underwater seal)
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Already received 6 pack cells, 1 DIVC cycle and 6 pints
crystalloids
requiring low dose intropes
on SIMV, FiO2 0.5/PEEP 10/PS 12
BP 107/67 on IV noradrenaline 4mg at 2ml/hr
HR 94-101
spo2 100%
Lungs : equal air entry. normal percussion note
Abdo : soft. non-distended
urine output good
Chest tube A 400cc,fluctuating but not bubbling
Chest tube B 50cc - not fluctuating and not bubbling
- noted in CT thorax the chest tube is outside the thoracic
cavity with extensive subcutaneous emphysema

Treatment
Laboratory Investigation

ABG pH 7.249/pO2 85.4/pCO2 50.8/HCO3 20.4/BE -7.4

FBC trend Hb 14--> 12--> 11.5/wcc 22.9/platetet 300->
90/Hct 39.4--> 33.2
31/08/2013
Full Blood Count (FBC)
10:48 White Blood Cell 25.57 x10^9/L ABNORMAL ( 4.0011.00)
10:48 Haemoglobin 11.5 g/dL Abnormal ( 13.0- 17.0)
10:48 Platelet 111 x10^9/L (110-450)
PT/APTT Test
10:48 Prothrombin Time 14.20 sec ABNORMAL ( 9.1012.80)
10:48 International Normalised Ratio (INR) 1.26
10:48 Activated Partial Thromboplastin Time 41.7 sec
ABNORMAL ( 27.5- 39.8)
Renal Profiles

Radiological Investigation

10:48 Urea 4.0 mmol/L ( 3.2- 7.4)

10:48 Sodium 143 mmol/L (136-145)
10:48 Potassium 3.50 mmol/L ( 3.50- 5.10)
10:48 Chloride 112.0 mmol/L ABNORMAL ( 98.0- 107.0)
10:48 Creatinine 58.7 umol/L Abnormal ( 64.0- 111.0)
31/08/2013
12:29 Emerg.Abdomen CTA THORAX, CECT THORAX AND
ABDOMEN DATED 31/8/13
FINDINGS:
The lower right chest tube is located extrathoracic
posteriorly with its tip in within chest wall.
However, the upper rigth chest tube is located
intrathoracic with tips tip in the pleural space and
indenting the lung parenchyma.
Multiple right 3rd to 10th rib fractures with flail segments
from right 4th to 9th ribs
Fracture lateral border of the right scapula
Subcutaneous emphysema on the right thorax until the
right upper abdomen
Bilateral pneumothorax (R>L)
Bilateral lung contusions with ground glass opacities.
Haemothorax and consolidation likely pulmonary
hemorrhage in the right lung.
There are several air filled cyst in the right lower lobe
within the area of sconsolidationin communication with
the bronchioles (Se 7/254) suggestive of lung laceration.
No pneumomediastinum
Periportal oedema in the liver and distended IVC may be
related to fluid resuscitation.
The liver shows homogenous enhancement. No contusion
or laceration seen.
The pancreas, spleen, gallbladder,both adrenals and both
kidneys also show no contusion or lacerations.
The urinary bladder is regular in outline with contrast
within. Urinary catheter balloon in situ.
No thickened bowels.
Minimal free fluid in the peritoneal space.
There is minimal soft tissue hematoma with pockets of air
surrounding the left femoral vessel likely post cannulation.
No pneumoperitoneum.
No vertebral fractures.
IMPRESSION:

New Orders / Mx Changes

1. Bilateral pneumothorax and lung contusions.

2. Right 3rd to 10th s rib fractures with flail segments as
described.
3. Right hemothorax with pulmonary pseudocyst at the
lower lobe likely from lung laceration.
4. Extrathoracic lower right chest tube with extensive
subcutaneous emphysema.
5. Periportal fluid with minimal ascites likely related to
vigorous fluid resuscitation. No evidence of intraabdominal injury.
to remove chest tube B as it is not functioning and outside

the thoracic cavity

to repeat CXR post chest tube removal

Authorship and Healthcare Provider List

House Officer
Medical Officer
Specialist

:
:
:

Dr Nurul Aimi
Dr Deva
Ms Safa

Note Type : GS Ward Progress Notes Med/Anc Service : Anaesthesiology

Date/Time : 01/09/2013 00:26
Performed By : Noornadia Bt Yahaya,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Dr Razaleigh/ Dr Deva

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 (car crushed into the drain)

Issues :
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
- 2 chest tubes inserted in ED, 1st chest tube inserted,
drained 400cc blood, 2nd chest tube inserted, drained
50cc of blood (minus 300cc underwater seal)
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
currently on sedation midamorphine
intubated on SIMV mode F102 0.4
BP: 107/67 on Iv norad 4mg @ 2m l/hr
HR; 94-101
P/a: soft, not distended, ches tube dressing soaked
chest tube : 50 cc hemoserous , fluctuatingn ,nut not
bubbling
ABG less acidotic
chest x-ray Post chest tube : done

Treatment
Laboratory Investigation
New Orders / Mx Changes

:
:

HB: 12 ---> 11.5/ wcc 22.9 / PLT 300

Plan:
continue as plan
to review repeated chest x-ray cm
to change dressing at chest tube

Authorship and Healthcare Provider List

Note Type : GS Ward Progress Notes

Date/Time : 01/09/2013 13:23

Med/Anc Service : Anaesthesiology

Performed By : Renukha Gunaselan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Ms Safa , Dr Nitin , Dr Nisa

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crushed into the drain )

PTD1
Under surgical for :
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
- 2 chest tubes inserted in ED, 1st chest tube inserted,
drained 400cc blood, 2nd chest tube inserted, drained
50cc of blood (minus 300cc underwater seal)
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Intubated
Sedation was weaned off this morning
Transfused total of 6 pints PC and 1 cycle of DIVC
Chest tube --> total drainage of 400cc yesterday ,
fluctuating
BP supported by Ivi Norad
Good oxygenation
Hb static 11
Pain controlled
Subcutaneous emphysema --> not worsening
Afebrile
BP 141/117
PR 68
SPO2 100% on SIMV
Lungs reduced a/e over right lower zone
P/a soft non tender , not distended
Chest tube --> nil , fluctuating not bubbling
CXR reviewed --> lungs expanded, chest tube tip insitu

Treatment
Laboratory Investigation

01/09/2013
Cardiac Enzymes (CK, AST & LDH)

New Orders / Mx Changes

02:15 Aspartate Transaminase 55 U/L ABNORMAL (5-34)

02:15 Lactate Dehydrogenase 582 U/L ABNORMAL (125220)
02:15 Creatine Kinase 2099 U/L ABNORMAL (30-200)
Full Blood Count (FBC)
02:15 White Blood Cell 14.70 x10^9/L ABNORMAL ( 4.0011.00)
02:15 Haemoglobin 12.4 g/dL Abnormal ( 13.0- 17.0)
02:15 Platelet 130 x10^9/L (110-450)
02:15 Magnesium 1.19 mmol/L ABNORMAL ( 0.66- 1.07)
02:15 Phosphate Inorganic 0.77 mmol/L ( 0.74- 1.52)
PT/APTT Test
02:15 Prothrombin Time 13.20 sec ABNORMAL ( 9.1012.80)
02:15 International Normalised Ratio (INR) 1.17
02:15 Activated Partial Thromboplastin Time 36.1 sec
( 27.5- 39.8)
Renal Profiles
02:15 Urea 5.3 mmol/L ( 3.2- 7.4)
02:15 Sodium 141 mmol/L (136-145)
02:15 Potassium 3.20 mmol/L Abnormal ( 3.50- 5.10)
02:15 Creatinine 62.1 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
02:15 Protein, Total 44.0 g/L Abnormal ( 64.0- 83.0)
02:15 Bilirubin, Total 120.7 umol/L ABNORMAL ( 3.420.5)
02:15 Alanine Transaminase (SGPT) 40 U/L
02:15 Albumin 22 g/L Abnormal (35-50)
02:15 Alkaline Phosphatase 38 U/L Abnormal (40-150)
02:15 Amylase 68 U/I (25-125)
02:15 Calcium 1.93 mmol/L Abnormal ( 2.10- 2.55)
Cont supportive care

Authorship and Healthcare Provider List

House Officer

Dr Renukha

Addendum Created By: Renukha Gunaselan, Dr, Date/Time: 01/09/2013 14:11:23

Correction
Hb is 12.4 post transfusion

Note Type : GS Ward Progress Notes Med/Anc Service : Anaesthesiology

Date/Time : 01/09/2013 23:14
Performed By : Noornadia Bt Yahaya,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Dr Nitin

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crushed into the drain )

PTD2

Under surgical for :

1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
currently CPAP mode, fi02: 0.4
on tappering dose of norad
already off sedation
T; afebrile
BP; 122/65
PR: 98
spo2: 100% under CPAP
ABG less acidotic
u/o: 40-50ml/hr
Lung: equal A/E, chest tube site not soaked

Treatment
Current Medication
Laboratory Investigation
New Orders / Mx Changes

:
:
:

chest x -ray: chest tube not in

HB: 12.4 ( postransfusion 1 pint on 30/8/2013 )
Plan:
continue as planned
Continue ICU supportive care
KIV to off chest tube cm

Authorship and Healthcare Provider List

Note Type : GS Ward Progress Notes

Date/Time : 02/09/2013 07:57

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
- has had 6 pintc of PC anfd 1 cycle of DIVC transfused

-initial drainage from chest tube insertion was 1L of blood

followed by 300 cc in the next one hour, subsequently
stabilized
- Drainage trend: 1L--> 300cc (blood)--> 400 cc--> 20cc
(hemoserous)

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Overall condition improving
GCS full (still intubated), On CPAP: FiO2: 0.3/ CVP: 8/
PEEP: 10/ PS: 12
no signs of active bleeding from chest injury, chest
drainage yesterday: 20cc--> hemoserous
Hb trend: 11.5--> 12.4--> 11.1/Plt: 108/. INR: 1.1 (no
blood treansfusions past 24 hours)
BP still supported by tappering dosea IVI Norad, no
hypotensive episodes
HR: 70.-80 bpm, sinus rhythm
Good U/O
Chest tube: fluctuating, but not bubbling
p/a: soft, not distended
tolerating NG feeding well

Treatment
Laboratory Investigation

ABG: pH: 7.352/ PCO2: 46.7/ P{O2: 151/ SpO2: 99.1/

Lac: 1.8/ BE: 0.4/ HCO3: 24.2
02/09/2013
Cardiac Enzymes (CK, AST & LDH)
01:26 Aspartate Transaminase 35 U/L ABNORMAL (5-34)
01:26 Test Method : NADH without P5P
01:26 Lactate Dehydrogenase 345 U/L ABNORMAL (125220)
01:26 Test Method : Lactate to pyruvate
01:26 Creatine Kinase 1125 U/L ABNORMAL (30-200)
01:26 Test Method : NAC
Full Blood Count (FBC)
01:26 White Blood Cell 16.07 x10^9/L ABNORMAL ( 4.0011.00)
01:26 Haemoglobin 11.1 g/dL Abnormal ( 13.0- 17.0)
01:26 Haematocrit 32.3 % Abnormal ( 40.0- 54.0)
01:26 Platelet 108 x10^9/L Abnormal (110-450)
01:26 Magnesium 0.78 mmol/L ( 0.66- 1.07)
01:26 Phosphate Inorganic 0.73 mmol/L Abnormal ( 0.741.52)
PT/APTT Test
01:26 Prothrombin Time 12.60 sec ( 9.10- 12.80)

01:26 International Normalised Ratio (INR) 1.12

01:26 Activated Partial Thromboplastin Time 34.9 sec
( 27.5- 39.8)
Renal Profiles
01:26 Urea 4.1 mmol/L ( 3.2- 7.4)
01:26 Sodium 138 mmol/L (136-145)
01:26 Potassium 2.90 mmol/L Abnormal ( 3.50- 5.10)
01:26 Chloride 105.0 mmol/L ( 98.0- 107.0)
01:26 Creatinine 54.8 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
01:26 Protein, Total 43.0 g/L Abnormal ( 64.0- 83.0)
01:26 Globulin 23 g/L (19-33)
01:26 Albumin/Globulin Ratio 0.86
01:26 Bilirubin, Total 47.3 umol/L ABNORMAL ( 3.4- 20.5)
01:26 Alanine Transaminase (SGPT) 34 U/L
01:26 Albumin 20 g/L Abnormal (35-50)
01:26 Alkaline Phosphatase 47 U/L (40-150)

Radiological Investigation

New Orders / Mx Changes

01:26 Calcium 1.92 mmol/L Abnormal ( 2.10- 2.55)

01:26 Amylase 47 U/I (25-125)
CXR: slight improvement but still has residual
pneumothorax and ongoing lung contusion
To continue supportive care

Authorship and Healthcare Provider List

House Officer

Note Type

Dr Deepa

: GS Ward Progress
Notes

Date/Tim
: 02/09/2013 23:13
e

Med/Anc
: Anaesthesiology
Service
: Nurul Aimi binti Abd
Performed By
Ghani,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Mr Lim, Dr Lee YS and Dr Chua

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
- has had 6 pintc of PC anfd 1 cycle of DIVC transfused
- 2 chest tubes inserted by ED team. 1 chest tube
removed on 31/08/2013 and another chest tube removed

today, 02/09/2013

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
extubated today
right chest tube removed this afternoon
c/o SOB
BP stable unsupported
HR 80-90
spO2 79-90% under venti mask 60% 12L/min
Lungs : absent air entry at the right side up to mid zone
Abdo : soft and non-tender
urine output good
Lungs : absent air entry

Treatment
Laboratory Investigation

Radiological Investigation
New Orders / Mx Changes

:
:

ABG under venti masl 60% pH 7.418/pO2 86/pCO2

46.4/HCO3 28.6/BE 5.1/lactate 1
CXR : bilateral lung contusion, lungs not expanded.
to insert chest tube

Authorship and Healthcare Provider List

House Officer
Medical Officer
Specialist

Note Type

:
:
:

Dr Nurul Aimi
Dr Lee YS and Dr Chua LS
Mr Lim

: GS Ward Progress
Notes

Date/Tim
: 02/09/2013 23:49
e

Med/Anc
: Anaesthesiology
Service
: Nurul Aimi binti Abd
Performed By
Ghani,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Ad Hoc Entry
Dr Lee YS

Complaint(s) and Progress

Complaints, If Any :

Chest tube inserted by Dr Lee YS using aseptic technique

Areas cleaned and draped
incision made
chest tube, size 32Fr inserted, anchored at 10
connected to underwater seal
20cc blood drained
post chest tube insertion, noted fluctuating
spO2 picked up to 95%

Treatment
Authorship and Healthcare Provider List
House Officer

Dr Nurul Aimi

Note Type : GS Ward Admission

Date/Time : 06/09/2013 18:06

Med/Anc Service : General Surgery

Performed By : Guan Jade Pei, Dr

GS Ward Admission
Introductory Data
Reason For Admission
SGA
Nutritional Assessment

:
:
:

Transfer in summary from ICU

A - Normal
0

History
The History Of Present Illness :

Alleged MVA on 31/08/2013 ( car crashed into the

drain )
Sustained:
1. Severe chest injury with massive right haemothorax,
bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
Intubated on arrival, was extubated on 02/09/13
Post extubation developed right lung collapse,
unresolved lung contusion
Chest tube was incerted on 31/8/2013 and off on
2/9/2013
Reintubated on 03/09/13 for respiratory distress ,
extubated to VM today noon
uneventful extubation
Repiratory C&S 03/09/13 grew Klebsiella spp,
sensentive to augmentin,
was initially started on IV rocephine d4--> de-escalate
to IV Augmentin today
Was in ICU for 7days

Co-morbid Illness(es) and Treatment

Co-morbid Illness(es)
Current Medication

:
:

Investigation

IV Augmentin 1.2 g tds ---> D1

IV tramal 50 mg QID
T Vit C 1000 mg OD
T PCM 1g QID
Syr Lactulose 20 ml 4H
T Ranitidine 150 mg BD
06/09/2013
Bilirubin Total and Direct

15:15 Bilirubin, Direct 104.4 umol/L ABNORMAL ( 0.015.4)

15:15 Billirubin, Indirect 27.2 umol/L ABNORMAL ( 0.08.6)
Cardiac Enzymes (CK, AST & LDH)
04:47 Aspartate Transaminase 23 U/L (5-34)
04:47 Lactate Dehydrogenase 342 U/L ABNORMAL
(125-220)
04:47 Creatine Kinase 170 U/L (30-200)
04:47 C-Reactive Protein (CRP) 19.90 mg/dL
ABNORMAL ( 0.01- 0.82)
Renal Profiles
04:47 Urea 4.8 mmol/L ( 3.2- 7.4)
04:47 Sodium 131 mmol/L Abnormal (136-145)
04:47 Potassium 3.40 mmol/L Abnormal ( 3.50- 5.10)
04:47 Creatinine 49.6 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
04:47 Protein, Total 49.0 g/L Abnormal ( 64.0- 83.0)
04:47 Bilirubin, Total 112.2 umol/L ABNORMAL ( 3.420.5)
04:47 Alanine Transaminase (SGPT) 27 U/L
04:47 Albumin 19 g/L Abnormal (35-50)
04:47 Alkaline Phosphatase 97 U/L (40-150)
04:47 Amylase 21 U/I Abnormal (25-125)
04:47 Calcium 1.97 mmol/L Abnormal ( 2.10- 2.55)
Full Blood Count (FBC)
03:44 White Blood Cell 14.87 x10^9/L ABNORMAL
( 4.00- 11.00)
03:44 Haemoglobin 10.2 g/dL Abnormal ( 13.0- 17.0)
03:44 Haematocrit 29.6 % Abnormal ( 40.0- 54.0)
03:44 Platelet 204 x10^9/L (110-450)
03:44 Magnesium 0.94 mmol/L ( 0.66- 1.07)
PT/APTT Test
03:44 Prothrombin Time 10.80 sec ( 9.10- 12.80)
03:44 International Normalised Ratio (INR) 0.96
03:44 Activated Partial Thromboplastin Time 35.3 sec (
27.5- 39.8)

Allergies and Alerts

Personal and Family history
Smoking
Alcohol

:
:

No
No

Currently
Comfortable on VM 60%
No SOB/ chest pain
Good UO--. 60cc/hr

Physical Examination
General

O/e
Alert conscious
Clinically not pale
jaundice at sclera

Hydration fair
Crt<2sec
Warm peripheries
not tachypnoeic, RR 18
not tachycardic
Temp 37
BP 115/73
PR 84
SPo2 97% on VM 60%
Lungs: left side clear, right side coarse crepts til mid
zone
CVS: DRNM
P/a: soft, non tender

Summary
:

Plan Of Management

Monitor vitals signs, SPO2

Restart feeding (Enercal 7 sccops + 300mls H20) run
at 60mls/Hr for 5hours and rest 1Hr
encourage IS
chest and limb physio
Continue analgesia
Continue antibiotics

Authorship and Healthcare Provider List

House Officer

Dr Jade

Note Type : GS Ward Progress Notes

Date/Time : 03/09/2013 08:59

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Difficult ventilation, extubated yesterday, was on VM 60%
and destaurated, subsequently placed on CPAP mask:

FiO2: 0.5/ CVP: 15/ PEEP: 6, saturating at 97%

Tachypneoic, pain score: 7-8/10
Chest tube: fluctuating, 190cc blood stained fluid
Hb trend: 11.1--> 11, Plt: 108/ INR: 0.96

Treatment
Laboratory Investigation

Radiological Investigation

New Orders / Mx Changes

ABG: pH: 7.4/ PCO2: 43.5/ PO2: 84.9/ Sat: 97.7/ HCO3:
26/ BE: 2.0
CXR: slight improvement however still shows ALI picture
--> ARDS
P/F ratio: 169
Continue supportive care
Resume NG feeding
Suggest to step up anelgesia

Authorship and Healthcare Provider List

House Officer

Dr Deepa

Note Type : GS Ward Progress Notes

Date/Time : 03/09/2013 12:30

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Afternoon Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Reintubated and sedated this morning in view of
respiratory distress
patient was in severe pain
Chest tube removed by ICU team
BP slightly on lowish side (90-95/55-60 mmhg)
Ventilated on CPAP: FiO2: 0.5 / PEEP:10 /PS: 10 / CVP:
15
p/a: soft, not distended

Treatment
Current Medication
New Orders / Mx Changes

:
:

Midamorphine infusion
To resume NG feeding
Continue supportive care

Authorship and Healthcare Provider List

House Officer

Note Type

Dr Deepa

: GS Ward Progress
Notes

Date/Tim
: 03/09/2013 22:25
e

Med/Anc
: Anaesthesiology
Service
: Aimi Mastura Binti
Performed By
Shafie,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Dr. Razaleigh

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Admitted to ICU for hypovolaemic shock secondary to

chest trauma
Chest tube removed by ICU team yesterday
BP : 90-98/ 55-60
Ventilated on CPAP: FiO2: 0.5 / PEEP:10 /PS: 10 / CVP:
15
p/a: soft, not distended

Treatment
Current Medication
Laboratory Investigation

:
:

Midamorphine infusion
04/09/2013
Full Blood Count (FBC)
06:02 White Blood Cell 17.02 x10^9/L ABNORMAL ( 4.0011.00)
06:02 Haemoglobin 11.3 g/dL Abnormal ( 13.0- 17.0)
06:02 Haematocrit 31.9 % Abnormal ( 40.0- 54.0)
06:02 Mean Cell Haemoglobin Concentration 35.4 g/dL
( 31.0- 37.0)

New Orders / Mx Changes

06:02 Red Cell Distribution Width 13.8 % ( 11.5- 14.5)

06:02 Platelet 157 x10^9/L (110-450)
PT/APTT Test
06:02 International Normalised Ratio (INR) 1.13
Renal Profiles
06:02 Urea 6.8 mmol/L ( 3.2- 7.4)
06:02 Sodium 134 mmol/L Abnormal (136-145)
06:02 Potassium 4.40 mmol/L ( 3.50- 5.10)
06:02 Creatinine 60.1 umol/L Abnormal ( 64.0- 111.0)
To resume NG feeding
Continue supportive care

Authorship and Healthcare Provider List

Addendum Created By: Aimi Mastura Binti Shafie,DR, Date/Time: 04/09/2013 07:40:16

SB Mr. Vena

Note Type : GS Ward Progress Notes

Date/Time : 04/09/2013 10:31

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Progress Since Last Review :

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
Difficult ventilation, was re intubated yesterday afternoon
Ventilated on SIMV: FiO2: 0.4 / PEEP:8 /PS: 10 / CVP: 7
BP on lowish side (85-89/50-55 mmhg), supported by IV
Norad 4 mg @5ml/hr
Hb static: 11---> 11.3
Tolerating feeding: Enercal @ 60ml/hr

Treatment
Laboratory Investigation

ABG: pH: 7.445/ PCO2: 45.9/ PO2: 95.3/ O2 Sat: 98/

Lac: 1.3/ BE: 6.9/ HCO3: 30.4
04/09/2013
Cardiac Enzymes (CK, AST & LDH)
06:02 Aspartate Transaminase 22 U/L (5-34)
06:02 Test Method : NADH without P5P

06:02 Lactate Dehydrogenase 354 U/L ABNORMAL (125220)

06:02 Test Method : Lactate to pyruvate
06:02 Creatine Kinase 667 U/L ABNORMAL (30-200)
06:02 Test Method : NAC
Full Blood Count (FBC)
06:02 Haemoglobin 11.3 g/dL Abnormal ( 13.0- 17.0)
06:02 Haematocrit 31.9 % Abnormal ( 40.0- 54.0)
06:02 White Blood Cell 17.02 x10^9/L ABNORMAL ( 4.0011.00)
06:02 Platelet 157 x10^9/L (110-450)
06:02 Magnesium 0.84 mmol/L ( 0.66- 1.07)
06:02 Phosphate Inorganic 1.06 mmol/L ( 0.74- 1.52)
PT/APTT Test
06:02 Prothrombin Time 12.70 sec ( 9.10- 12.80)
06:02 International Normalised Ratio (INR) 1.13
06:02 Activated Partial Thromboplastin Time 38.2 sec
( 27.5- 39.8)
Renal Profiles
06:02 Urea 6.8 mmol/L ( 3.2- 7.4)
06:02 Sodium 134 mmol/L Abnormal (136-145)
06:02 Potassium 4.40 mmol/L ( 3.50- 5.10)
06:02 Chloride 97.0 mmol/L Abnormal ( 98.0- 107.0)
06:02 Creatinine 60.1 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
06:02 Protein, Total 50.0 g/L Abnormal ( 64.0- 83.0)
06:02 Globulin 28 g/L (19-33)
06:02 Albumin/Globulin Ratio 0.78
06:02 Bilirubin, Total 123.0 umol/L ABNORMAL ( 3.420.5)
06:02 Alanine Transaminase (SGPT) 26 U/L
06:02 Albumin 22 g/L Abnormal (35-50)
06:02 Alkaline Phosphatase 56 U/L (40-150)

Radiological Investigation
New Orders / Mx Changes

:
:

06:02 Amylase 16 U/I Abnormal (25-125)

06:02 Calcium 2.13 mmol/L ( 2.10- 2.55)
C XR: improving but still has ALI picture: PF ratio: 238
To continue supportive care

Authorship and Healthcare Provider List

House Officer

Dr Deepa

Note Type : GS Ward Progress Notes

Date/Time : 04/09/2013 14:12

GS Ward Progress Notes

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

Introductory Data
Review Type
Reviewed By

:
:

Afternoon Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Progress Since Last Review :

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
No significant new changes since morning
still intubated, on CPAP FiO2: 0.3/ CVP: 9/ PS: 10, GCS
full
Ongoing sepsis, in shock, BP supported on IV Norad 4 mg
@5ml/hr
U/O good
tolerate feeding @ 60mls/h

Treatment
Laboratory Investigation

New Orders / Mx Changes

ABG: pH: 7.465/ PO2: 99.7/ PCO2: 42.2/ O2 Sat: 98.6/

Lac: 1.2/ BE: 6.1/ HCO3: 29.9
Continue supportive care

Authorship and Healthcare Provider List

House Officer

Note Type

Dr Deepa

: GS Ward Progress
Notes

Date/Tim
: 04/09/2013 22:31
e

Med/Anc
: Anaesthesiology
Service
: Nurul Aimi binti Abd
Performed By
Ghani,DR

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Mr Najmi, Dr Nitin and Dr Swarna

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

Under surgical :
1. Severe chest injury with massive right

Progress Since Last Review :

haemopneumothorax, bilateral pneumothorax R>L

2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs
- was on chest tubes, last chest tube removed on
03/09/2013
on CPAP, FiO2 0.3
requiring inotropic support, tapering down
chest tube removed yesterday
reintubated yesterday in view of respiratory distress
E4VTM6
T 37.9
BP 115/56 on IV noradrenaline 4mg at 3ml/hr
HR 90-100
spO2 100%
Abdo : soft
Lungs : reduce air entry at the right lower zone
urine output good
Feeding : enercal 60ml/hr

Treatment
Laboratory Investigation

New Orders / Mx Changes

ABG pH 7.441/pO2 84.6/pCO2 43.2/HCO3 28.5/BE

4.9/lactate
Hb 11--> 11.3
continue supportive care

Authorship and Healthcare Provider List

House Officer
Medical Officer
Consultant

:
:
:

Dr Nurul Aimi
Dr Nitin and Dr Swarna
Mr Najmi

Note Type : GS Ward Progress Notes

Date/Time : 05/09/2013 09:24

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Difficulty in weaning of ventilation, GCS full

Ongoing sepsis/ SIRS, In septic shock--> Lungs
Febrile, haemodynamically dependent on low dose of
Norad 4mg @ 2ml/hr
HR: 100-100 bpm, sinus
Lungs: a/e equal bilaterally, bilateral crepitations
p/a: soft, non tedner, BS +

Treatment
Current Medication
Laboratory Investigation

:
:

IV Ceftriaxone
ABG: pH: 7.447/ PCO2: 42.3/ po2: 111/ sAT o2: 98.8/
OLac: 1.0/ HCO3: 28.5/ BE: 4.8
05/09/2013
Cardiac Enzymes (CK, AST & LDH)
05:03 Aspartate Transaminase 29 U/L (5-34)
05:03 Test Method : NADH without P5P
05:03 Lactate Dehydrogenase 352 U/L ABNORMAL (125220)
05:03 Test Method : Lactate to pyruvate
05:03 Creatine Kinase 359 U/L ABNORMAL (30-200)
05:03 Test Method : NAC
Full Blood Count (FBC)
05:03 White Blood Cell 15.85 x10^9/L ABNORMAL ( 4.0011.00)
05:03 Haemoglobin 10.7 g/dL Abnormal ( 13.0- 17.0)
05:03 Haematocrit 30.5 % Abnormal ( 40.0- 54.0)
05:03 Platelet 155 x10^9/L (110-450)
05:03 Magnesium 0.83 mmol/L ( 0.66- 1.07)
05:03 Phosphate Inorganic 0.77 mmol/L ( 0.74- 1.52)
PT/APTT Test
05:03 Prothrombin Time 11.80 sec ( 9.10- 12.80)
05:03 International Normalised Ratio (INR) 1.04
05:03 Activated Partial Thromboplastin Time 36.5 sec
( 27.5- 39.8)
Renal Profiles
05:03 Urea 5.2 mmol/L ( 3.2- 7.4)
05:03 Sodium 134 mmol/L Abnormal (136-145)
05:03 Potassium 3.70 mmol/L ( 3.50- 5.10)
05:03 Chloride 98.0 mmol/L ( 98.0- 107.0)
05:03 Creatinine 50.7 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
05:03 Protein, Total 49.0 g/L Abnormal ( 64.0- 83.0)
05:03 Globulin 29 g/L (19-33)
05:03 Albumin/Globulin Ratio 0.68
05:03 Bilirubin, Total 98.9 umol/L ABNORMAL ( 3.4- 20.5)
05:03 Alanine Transaminase (SGPT) 30 U/L
05:03 Albumin 20 g/L Abnormal (35-50)
05:03 Alkaline Phosphatase 70 U/L (40-150)

Radiological Investigation
New Orders / Mx Changes

:
:

CXR: improving
To continue supportive care

Authorship and Healthcare Provider List

House Officer

Dr Deepa

Note Type : GS Ward Progress Notes

Date/Time : 05/09/2013 15:25

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Afternoon Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Issue:
1/ Difficulty in weaning off ventilation
2/ Sepsis--. Lungs
General condition improving
better ventilation setting, on CPAP FiO2: 0.3, saturating at
98%
planned for extubation
BP stable, Norad support has been weaned off
GCS full
Chesty secretions+ upon suction

Treatment
Radiological Investigation
New Orders / Mx Changes

:
:

CXR: still has ALI picture

Continue supportive care

Authorship and Healthcare Provider List

House Officer

Note
Type

: GS Ward Progress
Notes

Dr Deepa

Med/Anc
: Anaesthesiology
Service

Date/Ti
me

: 05/09/2013 23:04

Performed By

: Muhammad Ishaq Md
AbdRahman,Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Evening Ward Round

Miss Safariny, Dr Razaleigh, Dr Deva, Dr Deve

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Issue:
1/ Difficulty in weaning off ventilation
2/ Sepsis--. Lungs
GCS E4VtM6
Currently BP stable on Norad 4mg running @ 0.2mls/hour
on CPAP: FiO2 0.3/ PEEP 8/ PS 10
SpO2 98%
Urine output good
Suction thick yellowish mucous with blood stained
Tolerating feeding (Enarcel)

Treatment
Laboratory Investigation
New Orders / Mx Changes

:
:

pH 7.440/ pCO2 39.6/ pO2 115/ HCO3 26.8/ BE 2.6

Continue supportive care

Authorship and Healthcare Provider List

House Officer

Dr Ishaq

Note Type : GS Ward Progress Notes

Date/Time : 06/09/2013 08:48

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Morning Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Issue:
1/ Difficulty in weaning off ventilation
2/ Sepsis-->Lungs
General condition stable, GCS full
However still has ongoing sepsis--> Lung infection (with
copious secretions)
Otherwise haemodynamically stable, unsupported
less tachycardic, HR: 90-95 bpm, sinus
pain score: 2/10 (on IV Morphine infusion)

Treatment
Current Medication
Laboratory Investigation

:
:

IV Ceftriaxone
ABG: pH: 7.406/ PCO2: 42.4/ PO2: 115/ O2 Sat: 98.8,
Lac: 1.0/ HCO3: 26/ BE: 1.9
06/09/2013
Cardiac Enzymes (CK, AST & LDH)
04:47 Aspartate Transaminase 23 U/L (5-34)
04:47 Test Method : NADH without P5P
04:47 Lactate Dehydrogenase 342 U/L ABNORMAL (125220)
04:47 Test Method : Lactate to pyruvate
04:47 Creatine Kinase 170 U/L (30-200)
04:47 Test Method : NAC
Renal Profiles
04:47 Urea 4.8 mmol/L ( 3.2- 7.4)
04:47 Sodium 131 mmol/L Abnormal (136-145)
04:47 Potassium 3.40 mmol/L Abnormal ( 3.50- 5.10)
04:47 Chloride 98.0 mmol/L ( 98.0- 107.0)
04:47 Creatinine 49.6 umol/L Abnormal ( 64.0- 111.0)
Liver Function Tests (LFT)
04:47 Protein, Total 49.0 g/L Abnormal ( 64.0- 83.0)
04:47 Globulin 30 g/L (19-33)
04:47 Albumin/Globulin Ratio 0.63
04:47 Bilirubin, Total 112.2 umol/L ABNORMAL ( 3.420.5)
04:47 Alanine Transaminase (SGPT) 27 U/L
04:47 Albumin 19 g/L Abnormal (35-50)
04:47 Alkaline Phosphatase 97 U/L (40-150)

04:47 Amylase 21 U/I Abnormal (25-125)

04:47 Calcium 1.97 mmol/L Abnormal ( 2.10- 2.55)
Full Blood Count (FBC)
03:44 White Blood Cell 14.87 x10^9/L ABNORMAL ( 4.0011.00)
03:44 Haemoglobin 10.2 g/dL Abnormal ( 13.0- 17.0)
03:44 Haematocrit 29.6 % Abnormal ( 40.0- 54.0)
03:44 Platelet 204 x10^9/L (110-450)

Radiological Investigation
New Orders / Mx Changes

:
:

03:44 Magnesium 0.94 mmol/L ( 0.66- 1.07)

03:44 Phosphate Inorganic 0.97 mmol/L ( 0.74- 1.52)
CXR: resolving ALI picture, PF ratio: 326
Continue supportive care

Authorship and Healthcare Provider List

House Officer

Dr Deepa

Note Type : GS Ward Progress Notes

Date/Time : 06/09/2013 16:34

Med/Anc Service : Anaesthesiology

Performed By : Deepa Sreenivasan, Dr

GS Ward Progress Notes

Introductory Data
Review Type
Reviewed By

:
:

Afternoon Ward Round

Dr Ashok

Complaint(s) and Progress

Complaints, If Any

Alleged MVA on 31/08/2013 ( car crashed into the drain )

GCS on arrival: 15
Under surgical for :
Sustained:
1. Severe chest injury with massive right
haemopneumothorax, bilateral pneumothorax R>L
2. Multiple right 3rd to 10th rib fractures with flail
segments from right 4th to 9th ribs

Progress Since Last Review :

Issue:
1/ Difficulty in weaning off ventilation
2/ Sepsis-->Lungs
General condition improving
GCS full, speaks in full sentences, on VM 60%, saturating
at 100%

Treatment
Laboratory Investigation

New Orders / Mx Changes

ABG: pH: 7.406/ PCO2 43.7/ PO2: 130/ O2 Sat: 98.7/

Lac:0.8/ HCO3: 26.6/ BE: 2.6
Awaiting transfer to ward
Breathing exercises
Incentive Spirometry
Acute cubicle nursing and monitoring

Authorship and Healthcare Provider List

House Officer

Dr Deepa

Note Type : Intensive Care Progress

Date/Time : 31/08/2013 08:51

Med/Anc Service : Emergency

Performed By : Cheong Chao Chia,DR

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition

ICu review at resus

activated by code blue
39 years old, Malay
alleged MVA, car crash into large drain
clinically diagnosed by ED as hemopneumothorax and
inserted right sided chest drain by ED team - drain fresh
blood 600 cc
issue;
1. hypovolemic shock secondary to chest trauma - drainage
from chest tube approaching 1 L
tarsnfused 5 pint PC, 6 pint crstalloid and 1 cycle DIVC
had difficulty in maintain ventilation ( possible consomitant
lung contusion - fresh blood from ETT suction)
intubated with full GCS

Monitoring Status

planning for CT thorax and angio, KIV embolisation or open

thoracotomy
intubated, sedated
pupil 3/3 reactive
pink
BP 118/78
PR 85
sat 100% on ALI ventilator settlinng (fIO2 1, low TV, high
PEEP, high rate)
PA soft
pelvic spring negative

Daily Investigation Status :

Plan

no long bone fracture

patient moves all four limbs prior to intubation
ABG pre transfer for CT scan- pH 7.46, pCO2 23, pO2 259
(FiO2 1.0) , Hb 9.5, lactate 4.0 , BE -6.1, HCO3 20
for CT thorax / angio as planned
to stanby 6 pint blood with 1 cycle DIVC if for open
thoracotomy
accept sat > 90%, paO2 > 65 mm Hg and permissive
hypercapnia
correct coagulopathy and anemia
above seen together with dr nadia, dr hafiza

Note Type

: Intensive Care
Progress

Date/Tim
: 31/08/2013 10:11
e

Med/Anc
: Emergency
Service
: Mohd Yusaini B Mohd
Performed By
Yusri,Dr

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition

ICU clerking
s/b dr shanthi ratnam
39 years old, Malay
alleged MVA, car crash into large drain
complaints of sob / difficulty in breathing
chest pain over right side
no other active complaints
sustained:
1. Rt hemopneumothorax and inserted right sided chest drain by
ED team - drain fresh blood 2000 cc
issues;
1. hypovolemic shock secondary to chest trauma
tarsnfused 5 pint PC, 6 pint crstalloid and 1 cycle DIVC
had difficulty in maintain ventilation ( possible consomitant lung
contusion - fresh blood from ETT suction)
intubated with full GCS
back from CT thorax and angio, KIV embolisation or open
thoracotomy

Monitoring Status

further hx
s/t family member
divorcee, have 2kids staying with his mother
MVA occured at Bukit beruntung
intubated
sedated with MM 10mls/h
BP 113/63 (84) unsupported
PR 104
spo2 100% on simv fio2 1
pupil 3/3 R
pink
lungs: 2 chest tubes on Rt lung
reduced A/E Rt side
cvs drnm
PA soft not distended
CBD inserted
calves supple

lying on spinal board + cervical collar

1pint gela on going
Other Interventions :
:

Plan

Note Type

no radiological images uploaded yet

bedside echo by Dr Shanthi
good contractility, IJC 1.6cm, no free fluid in abdomen, kidney
normal
off cervical colar and spinal board if clear
To review all imaging once uploaded
to reduce sedation if no head injury
rpt CXR at 6pm-->to look for pneumothorax
to give iv gela 250mg stat
start iv noradrenaline 1mls/H
tx 1pint PC

: Intensive Care
Progress

Date/Tim
: 02/09/2013 11:30
e

Med/Anc
: Anaesthesiology
Service
: Nur Akmarina Bt Mohd Isa,
Performed By
Dr

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition :
Monitoring Status :

Plan

alleged MVA sustained multiple right rib fracture (3rd -10th rib)
massive haemopneumothorax causing hypovolumic shock on
admission
GCs E4VtM6
good chest expansion
ETT suction blood stained
hemodynamic stable unsupported
Lungs good air entry bilaterally
no subcutaneous emphysema
extubated well to VM 60%
right chest drain was off under aseptic technique
repeat CXR post removal chest drain
reduce MAP to 65mmHg
incentive spirometry
cont paracetamol and tramadol
KIV to start PCA morphine if pain not well controlled

Note Type : Intensive Care Progress

Date/Time : 01/09/2013 11:50

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition :

Entry by syaireen

Med/Anc Service : Anaesthesiology

Performed By : Shanthi Ratnam, Dr

39 years old, Malay gentlemen

alleged MVA, car crash into large drain
Post MVA day 2 with multiple rib # with Rt hemopneumothorax
2 chest tube inserted -- one of the tube off -- causing s/c emphysema

Monitoring Status :

Plan

Note Type

US Rt side thorax --> not much fluids for chest tube insertion, IVC
1.5 (20% collapse)
CXR today showed evidence of lung contusion -- Rt Lower lobe,no
pneumothorax
intubated
sedated with MM 10mls/h
BP 101/61 (MAP 70)
HR 71
spo2 100%
afebrile
Lungs : reduced AE Rt Lower Lobe , anterior good AE
IV Gelafundin bolus 2pints
Reduce Norad
Off sedation
IV Tramadol 50mg 6hrly
T.PVM 1g 6hrly
Vit C 1/1 OD
No need for new chest tube insertion

: Intensive Care
Progress

Date/Tim
: 03/09/2013 10:58
e

Med/Anc
: Anaesthesiology
Service
: Nur Akmarina Bt Mohd Isa,
Performed By
Dr

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition :

39years old Malay man

alleged MVA sustained multiple rib fracture with haemopneumothorax
post extubation developed right lung collapse, unresolved lung
contusion
chest drain reinserted by surgical team
reintubated this morning in view of respiratory distress
induction given IV fentanyl 100mcg, Iv midazolam 5mg and IV
scholine 100mg,
intubated with ETT size 8, anchored at 21cm, CL I
on review
intubated sedated
warm peripheries
BP 129/70 unsupported
HR 127
Lungs reduce air entry right lower zone
CVS no murmur
P/A soft tolerated feeding

Plan

Note Type

NBO x 3/7
repeat CXR post intubation
send tracheal aspirate culture
repeat septic wokrout if another spike temeprature
ravin enema 11/11 stat

: Intensive Care
Progress

Date/Tim
: 04/09/2013 11:00
e

Med/Anc
: Anaesthesiology
Service
: Mohd Yusaini B Mohd
Performed By
Yusri,Dr

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition

Monitoring Status

D5 ICU
39years old Malay man
alleged MVA sustained multiple rib fracture with
haemopneumothorax
post extubation developed right lung collapse, unresolved
lung contusion
chest drain reinserted by surgical team
reintubated yesterday in view of respiratory distress
GCS full on MM 1mls/h
pupils 3/3 R
intubated
BP 102/51 (68) on NA 5mls/h
PR 88
T 36
spo2 98% on simv
lungs reduced A/E Rt LZ
PA soft not distended
TED stocking on
bed sore grade 2
BO x1
tolerate feeding 60mls/h
not in pain

Daily Investigation Status :

:
Plan

secretion thick yellowish

CK downgoing trend
trace cultures
mg so4 10mmol
cont ceftriaxone

Note Type : Intensive Care Progress

Date/Time : 05/09/2013 09:37

Med/Anc Service : Anaesthesiology

Performed By : Chong Yek Ying,DR

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition :

s/w dr Zurita
day 6 ICU admission
39 year old gentleman

Monitoring Status :

Alleged MVA sustained:

1/ multiple rib fracture with hemopheumothorax
-post extubation developed right lung collapse, unresolved lung
contusion
- chest drain reinserted by surgical team , currently removed
- re-intubated on 3/9/13 due to respiratory distress
intubated
not sedated, on IV Morphine 2ml/hr
ventilated on CPAP
tolerating feeding well
GCSE4VtM6
pupils 2/2 reactive
BP: 114/60 mmhg
HR 107
spo2: 100%
MAP 77 supported with SS noradrenaline 2ml/hr
good cough and gag reflex
lungs: fair air entry, slight reduce a/e on right lower zone.
- moderate yellowish secretion, spo2 96%
cvs: drnm
p/a: soft, not distended

Medication

Plan

i/o: +82cc
BO x 1
s/c heparin 5000u bd
iv ceftriaxone 2g OD
iv tramal 50mg qid
vitamin c 1/1 od
t. pcm 1g qid
t. ranitidine 150mg bd
syrup lactulose 20ml 4 hourly
reanchor ETT (done) and repeat CXR - done
continue syrup lactulose
aim for extubation
cont rocephin
MgSo4 10mmol/l
KMnPo4 10mmol/l
Trace cultures

Note Type

: Intensive Care
Progress

Date/Tim
: 06/09/2013 10:00
e

Med/Anc
: Anaesthesiology
Service
: Abu Hurairah B. Abu
Performed By
Samah,Dr

Intensive Care Progress Notes

PROGRESS OF PATIENT
General Condition

enrry by Aida Adnan

s/w Dr Zurita
day 7 ICU admission
39 year old gentleman
Alleged MVA sustained:
1) multiple rib fractures with hemopheumothorax
-post extubation developed right lung collapse, unresolved
lung contusion
- chest drain reinserted by surgical team ,already removed
- re-intubated on 3/9/13 due to respiratory distress

Monitoring Status

O/ E:
E4VtM6
intubated
not sedated
obeying commands
CVS : DRNM
BP : 135/ 71 unsupported
PR : 115
SpO2 : 100 %
good cough and gag reflex
ventilated on CPAP
ABG on CPAP : good oxygenation
Lungs : crepts over right side from mid to LZ, fairly clear on
the left side
Secretions : large amount, blood stained, no brnochial
breath sounds
PA : soft ,
tolerating feeding , NBO X 1 day
UO : 50 - 70 cc/ hr
i/ O : -ve balance 54 cc
TWC: 14 ( decreasing trend )
CRP : 25 --> 19
sputum C &S 3/9 : grew Klebsiella spp sensitive to
augmentin

currently on IV rocephine D 4
Daily Investigation Status :

03/09/2013
13:17 Culture&Sensitivity-Sputum ORGANISM COMMENTS
------------------------------------------------------------------------------KLNG Klebsiella sp.
ANTIBIOTIC SENSITIVITY
Cefuroxime 30 S
Gentamicin 10 S
Cefotaxime 30 S
Unasyn 20 S
Augmentin 30 S
S - Sensitive R - Resistant I - Intermediate

Plan

extubate today - done

mantain VM 60 %
for NBM 6H post extubation
ABG 1Hr post extubation
off rocephine
change to IV augmentin 1.2 g tds
encourage incentive spirometry
chest physio

Addendum Created By: Abu Hurairah B. Abu Samah,Dr, Date/Time: 06/09/2013 11:49:17

dor direct/ indirect bilirubin

Note Type : Nursing Report

Med/Anc Service : Emergency
Date/Time : 31/08/2013 07:44
Performed By : Norhamimah Bte Ahmad Shariff

Night Shift

31/08/2013
@6.10am
~new case from ambullance call acc by staff via strecher
~on arrival general condidtion alert and cocncious
~on arrival GCS 15/15
~vital sign sign checked and recorded

~pt on HFM oxygen 15L/min - aplly

~pt on cervical collar
c/o:sob / difficulty in breathing
chest pain over right side
c/o:car crash into a huge drain,complaints of sob / difficulty in breathing
s/b Dr Vino stat and ED team and as plan:
~inserted 2 chest tubes
-size 24 and 32 fr
~in view of SPo2 and blood pressure persistently low and chest remain hyperresonant
~chest tube inserted -> drained 700ml fresh blood
~patient not improved with initial chest tube -> second chest tube inserted on right side
~drained 300ml, clamped as total volume drained is 1L over less than one hour
~Intubate patient for airway protection - as spo2 78 % under hfm / hypotensive
~IVI midamorphine 3 ml/hour - in progress
medication given:
~IV morphine 6mg in total given
~IV tranexemic acid 1g stat-given
~1g tranexemic acid over 8 hours - in progress
Total fluid resuscitation :~4 pint pack cell / 3 pint colloid (noted developed urticaria)
~v/o from Dr Vino and as plan:
~ iv piriton 10mg stat
~iv hydrocortisone 200mg stat
~awaiting for surgical and anest team to review patient
@7.00am
~pass report to Sn Hasnor
sn hamimah/sn faathiah/ppp suhaiful
ed-resus

case is attended by anaesthesiology and surgical team

***case explained to brother in law- Mr. Hasbah

**allergic reaction to safe O blood bank mo Dr. Anis -mentioned has 2 more pint pc available- gxm code 3112
-if patient proceeds with surgical intervention in OT - 6 pints GSH available - code 3101
right

Note Type : Nursing Report

Date/Time : 31/08/2013 09:41

Med/Anc Service : Emergency

Performed By : Siti Hasnor bt Norhan

Morning Shift
7.00am
IMP:
1. Severe chest injury with massive right haemothorax
2. TRO intraabdominal injury
taken over case from sn hamimah, pt intubated and sedated
on cervical collar
on iv midamorphine 3ml in progress
cbd insitu
double chest tube at right sided
attempt by surgical and aneasth team
proceed with ct- thorax, ct - abdomen , ct - cervical done
transfer pt to ICU
pass over case to sn sharifah
total fluid resus :3 pint EO - completed
2 pint PC - completed
DIVC 1 cycle - completed
6 pint crstalloid - completed
sn hasnor

Note Type : Nursing Report

Date/Tim : 31/08/2013
e
11:27

Med/Anc
: Anaesthesiology
Service
Performed By : Syarifah Azliana bt Tuan Ahmad

Morning Shift
DAY 1 IN ICU
IMP:Allerged MVA with severe chest injury with massive Rt haemothorax
TRO Intraabdominal injury

10.10am
New case transfer in from ED via 5C
brought by stretcher accompanied by Dr Najwa ,sn and MA
On arrival general condition patient ill
Breathing supported with portable ventilator
attend stat, dr Najwa put partient on ventilator with SIMV mode setting FIO2:100 Rate:14
Peep:10 PS:12
AIBP:110/66mmHg Hr:100/min MAP:83mmhg
Patient on IV Midamorphine 1mg/ml run at 10ml hr
GCS:4/15, E1VTM2, both pupil 2mm equal and reactive to light
Patient on spinal board - Dr Yus order to not off yet - after Xray clear
Temp:33.5'c - put patient on bair hugger
all blood ix taken & despatched
10.18am
ABG taken - result seen by Dr Yus - order to increase rate to 16
Order to give 1gm KCL and 2gm ca.Gluconate - given as ordered
11.38am
ABG taken - result seen by Dr Yus
PCO2:50.8
Order to do regular suction due to large of secretion
12.30noon
start 1pint p/cell transfusion
order by Dr Shanthi to run IV Gela 250ml
2.00pm
General condtion patient remain ill
all nursing care rended

Note Type : Nursing Report

Date/Time : 31/08/2013 18:38

Med/Anc Service : Anaesthesiology

Performed By : Nurul Hayat Binti Mohd Zain

Evening Shift
31/08/2013
DAY 1 IN ICU
DIAGNOSE
sustained:
1. Rt hemopneumothorax and inserted right sided chest drain by ED team - drain fresh
blood 2000 cc
issues;
1. hypovolemic shock secondary to chest trauma
tarsnfused 5 pint PC, 6 pint crstalloid and 1 cycle DIVC
had difficulty in maintain ventilation ( possible consomitant lung contusion - fresh blood
from ETT suction)
intubated with full GCS
0200PM
General condition of patient critically ill
GCS 5/15(E1VTM3) and both pupil size 2mm reactive to light
Vital sign checked and recorded

AIBP 117/65mmHg,HR 83bpm,SPO2 100% and afebrile

Kept ventilated with SIMV setting mode,FIO2 0.5,PEEP 10,PS 12,RR 20bpm
BP supported with IV Noradrenaline 4mg/50mls D5 run 6mls/hly
Kept well sedated with IV Mida/morphine 60mg/60mls N/S run 6mls/hly
Patient on IVD QSD1 run 60mls/hly
Right chest tube intact-well draining
Arterial line and CVP line intact and functioning well
CBD intact with hourly urin output monitoring
0230PM
Confirm with DR Nadia
-can off cervical collar and spinal board
0240PM
Lower chest tube off done by DR Surgical team
-50ml hemoserous from chest tube
Order CXR done by DR
0300PM
Eye care and oral toilet done
Suctioning done with moderate fresh blood
Cough and gag rreflex present
0400PM
All listed medication given as ordered and recorded
ABG taken and recorded
Review done by DR
-Correct IV Mgso4 20MMOL and 1gm KCL
0500PM
Sponging done-no bedsore seen
Small laceration seen at back
0545PM
Call X-Ray done-3x no answer
0615PM-Call back-will come
0600PM
Ryles tube inserted done
-Start feeding clear fluid
-Decrease IVD QSD1 run 40mls/hly
0700PM
Suctioning done with moderate fresh blood
Cough and gag rreflex present
0800PM
ABG taken and recorded
Review done by DR
0900PM
Condition of patient remain same
Continue all GICU plan
All nursing care randered
Patient BNO

Note Type : Nursing Report

Date/Time : 01/09/2013 12:36

Med/Anc Service : Anaesthesiology

Performed By : Fatihah Binti Awang

Morning Shift
MOHD ASWADI BIN AB RAHMAN, 39 YEARS OLD, SB532421
DAY 2 IN ICU (31.8.2013)
DIAGNOSIS
Allerged MVA with
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
7.00am
Condition patient ill
GCS 11/15 (E1, VT, M3) both pupil size 2mm reactive to light
Patient breathing supported with ventilator mode SIMV setting FIO2: 0.4, RATE: 20,
PEEP: 10, PS: 12
On inotropes supported IV Noradrenaline 4mg/50ml D5% run at 9mls/hrs accoridng
to MAP>75-80mmHg
Vital sign checked and recorded AIBP: 107/58mmHg, HR: 87bpm, SPO2: 100%,
TEMP: 37.3c
On continous Ryle's tube feeding ensure run 80ml/hrs for 5hrs then rest 1hrstolerating well
ARRTLINE and CVPLINE intact and functioning well
CBD intact with hourly urine output monitoring
Chest tube A intact.
8.00am
All medication served to patient as order
Mouth and eye care done
Secretion from mouth large thick yellowish
Suction done secretion moderate thick blood stained sucked out from ETT
Gag reflex present
ABG taken
12.00noon
try CPAP but failed.
Seen by DR Shanthi
- no need chest tube.
- start iv tramal 50mg qid.
1.00pm
V/o by DR shanthi
- increase rate to 14.
2.00pm

Condition patient remain same

Continue GICU plan
All nursing care randed

Note Type : Nursing Report

Date/Time : 02/09/2013 09:24

Med/Anc Service : Anaesthesiology

Performed By : Nor Azlida Bt Abdullah

Morning Shift
DAY 3 IN ICU

DIAGNOSIS
39 years old, Malay gentlemen
alleged MVA, car crash into large drain
Post MVA day 3 with multiple rib # with Rt hemopneumothorax
2 chest tube inserted -- one of the tube off -- causing s/c emphysema
0700HR
General condition of patient concious and alert.Kept ventilated with CPAP Fio2:0.3 PEEP:10
PS:12
AIBP:123/70mmhg PR:89/min SPO2:100% T:Afebrile
GCS:E4 VT M6 Both pupil 2mm reactive to light
Currently patient on:IV Noradrenaline 4mg/50ml run 3ml/hr to keep map 75-80mmhg
On ryle's tube feeding 60ml/hr enercal in progress
Rt chest tube intact-flactuating seen
0730H
Suctioning done via ETT - moderate thick and fresh blood from ETT and moderate thick
yellowish via oral- good cough and gag refleks seen.
0800H
All medication given as due
ABG done - Review by Dr.Rina
0810H
Patient review by Dr.Ashok and surgical teams as order
-To continue supportive care
0930H
Patient review by Dr.Premala as verbally order
- Patient for NBM- done ryle'tube feeding withold and aspirate
- Started ivdrip QSD1 run at 60mls/hrs- done and in progress
1130H
Patient extubate to ventimask 60% 12liter/min - Spo2 95-98%- not respiratory distress

seen.
Iv Noradrenalin off regarding Map > 65mmhg
Rt Chest tube off by Dr.Rina - drain flow 30cc with heamoserouse
Order by Dr.Rina
1.Repeat CXR post removal chest drain- done review by Dr.Premala
2.Reduce MAP to 65mmHg
3.Incentive spirometry - given and teach to patient but patient looked weak and ball not
picked up
4.Cont paracetamol and tramadol
5.KIV to start PCA morphine if pain not well controlled
Verbally order by Dr.Rina to give iv lasix 10mg stat- given
1200H
All medication given as due
ABG done- Dr.to review
1340H
Chest x-ray review by Dr.Premala - verbally order kept patient in icu for 1 more day and kiv
for T/O if bed needed
1400H
Condition patient remain weak.
Stable via ventimask 60% 12liter/min
Latest observation Bp:98/60mmhg Hr:96Bpm RR:24/min Spo2:100%
Report done PBS Azlina

Note Type : Nursing Report

Date/Time : 02/09/2013 14:37

Med/Anc Service : Anaesthesiology

Performed By : Suriantika Binti Wagi

Evening Shift
Day 2 in icu 2/9/13
DIAGNOSIS
Allerged MVA with
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
1450H
During taking over report,general condition patient weak
kept spontaneous breathing withventimask 12l/min
GCS E4V5M6
Both pupil size 2mm/2mm reacting well to light.
vital sign checked and recorded ABP:102/62mmHg HR:72/min sPo2:99%
patient on IVD QSD1 run 60mls/hour

CVP and arterial line intact and functioning well

CBD intact with hourly urine output monitoring.
1600H
Oral toilet done,sponging and all dirty linen change.
Skin break down seen at sacral size 1cm.
Medication served as ordered.
Incentive spirometry excersice teach by physiotheraphy...no ball up.
1800H
ABG result review by Dr Yus...v/o continue same..
oral suctioning done..minimal thick and brownish..
medication given as ordered.
2000H
General condition patient weak
Still breathing with v/mask 12L/min
GCS E4V5M6 15/15
vital sign checked and recorded ABP:103/57mmHg HR:80/min T:36.5C Spo2:98%
Patient on contineus feeding 60mls/hours..tolerating well.
incentive spirometry 4 hourly done..
arterial line intact and functioning.
CBD intact and functioning with hourly urine output monitoring..urine output adequate.
nursing rended..
Nursing Care PLan
Problem:ineffective breathing effort due to pain
Nursing intervention:
1)Prop up patient
2)Monitor sPo2 >95%
3)Encaurage patient to do deep breathing excercise and cough excercise.
4)Incentive Spirometry 4 houly
5)Give analgesik as dr order;
Outcome
Patient spo2 >95%

Note Type : Nursing Report

Date/Time : 02/09/2013 21:08

Night Shift
Day 2 in icu 2/9/13

Med/Anc Service : Anaesthesiology

Performed By : Muhamad Zaini Bin Ahmad

DIAGNOSIS
Allerged MVA with
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
9pm
During taking over report,general condition patient weak
kept spontaneous breathing withventimask 12l/min
GCS E4V5M6
Both pupil size 2mm/2mm reacting well to light.
vital sign checked and recorded ABP:102/62mmHg HR:72/min sPo2:99%
patient on ryles tube feeding enercal 60ml/hr
CVP and arterial line intact and functioning well
CBD intact with hourly urine output monitoring.
12mid
rt chest tube inserted by surgical team
ABG done.
po2 61.9,dr yus noted.
neb salbutamol continuosly given.
1am
CXR done.
already review by dr yus.
abg done.
po2 67.3
dy yus noted.
2am
v/o by dr yus to start cpap mask
setting fio2 0.5,peep 6.
4am
All blood routine taken and despatch.
ABG done.
chest tube intact and functioning well.
fluctuating seen.
6am
general condition of patient remain same.
all nursing care rendered.
to continue icu management

Note Type : Nursing Report

Date/Tim : 03/09/2013
e
08:54

Med/Anc
: Anaesthesiology
Service
Performed By : Syarifah Azliana bt Tuan Ahmad

Morning Shift
AM Shift
Day 4 in icu 3/9/13
DIAGNOSIS
Allerged MVA with
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
7am
During taking over report,general condition patient is weak.
kept breathing with CPAP peep :6 fio2:0.5
Spo2:98% RR:33
GCS E4V5M6
Both pupil size 2mm/2mm reacting well to light.
vital sign checked and recorded ABP:133/68mmHg HR:108/min sPo2:98%
patient on ryles tube feeding enercal 60ml/hr - in progress.
CVP and arterial line intact and functioning well
CBD intact with hourly urine output monitoring.
Right chest tube intact.Fluctuating seen.Draining heamoserous fluid.
730am
Oral tiolet done.Oral cavity clean.No abnormality seen.Vaseline cream applied at both lips.
Eye toilet done.Both eyes clean.
Positioning patient on prop up position.
8am
Listed medication given as ordered.
Dxt:7.2mmol/l.
10am
Patient tachypnoec RR:42/min.Dr Yus noted.
Tachycardic 124 - 130/min.Patient complain pain.Dr Premalar noted.
1015am
Patient intubated by Dr Akmarina ETTsize 8mm marking :21cm.
On ventilator with simv mode setting.Fio2:0.5 rate:18 Tv :480 peep:8 Ps:10.
Sedated with iv Midamorphine run at 3mls/hour - in progress.
B/P:131/74mmhg HR:129/min.Spo2:98%.
ABG and CXR post intubation taken and review by Dr Akmarine.
12noon.
condition patient remain same.
Listed medication given as ordered.
tracheal aspirate culture - taken and sent as ordered by Dr Akmarina.
repeat septic workout if another spike temeprature

ravin enema 11/11 stat - given as ordered by Dr Akmarina.

patient BOx1 watery stool.Brownish colour.
1330pm
Chest tube off by Dr Premalar.Amoubt of chest tube 140cc heamoserous fluid.
All treatment carried out.
1400hr
General condition patient remain same
all nursing care rended

Note Type : Nursing Report

Date/Time : 03/09/2013 22:36

Med/Anc Service : Anaesthesiology

Performed By : Rosnah Bt Mohd Zainun

Night Shift
3/9/13
Day 4 in icu
Diagnosis:
Allerged MVA with
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
9pm
During taking over report,general condition patient weak
patient ventilated with setting mode SIMV fio2:0.6 rate:24 Peep:6
Ps:10 GCS:10/15( E4V1M6) both pupil 3mm reactive to ligth
vital sign checked and recorded ABP:106/61mmHg HR:93/min sPo2:98%
patient on ryles tube feeding enercal 60ml/hr
CVP and arterial line intact and functioning well
CBD intact with hourly urine output monitoring.
10.00pm
suction done with large loose blood stained
eye care and mouth toilet done
12.00mn
all due medication given
continue observation
2.00am
patient remain same
continue observation
4.00am
all blood investigation taken and sent

ABG taken and result recorded

suction done with large loose blood stained
5.00am
noted to dr rina urine output 5ml/hrs flushing done
v/o by doctor iv gela 250ml stat
6.00am
change ventilator setting fio2:0.5
6.30am
patient remain same
continue observation
all nursing care carried out

Note Type : Nursing Report

Date/Time : 04/09/2013 09:37

Med/Anc Service : Anaesthesiology

Performed By : Norlinda Bt. Mohamad, SN

Morning Shift
DAY 5 IN ICU(4/9/2013)
DIAGNOSIS
Allerged MVA with:
- Severe chest injury with massive right haemothorax
- TRO intrabdominal injury
0700H
General condition pt ill.
GCS 10/15(E3VTM6).Both pupil 3mm reactive to light
Ventilated via SIMV mode with setting FIO2 0.5 Peep 8 P/S 10 Rate 24
Vital sign checked and recorded
AIBP 108/58 mmHg HR 80 bpm SPO2 99% Temp Afebrile
BP supportted with IV Noradrenaline 4mg/50 ml D5% run 8 ml/H
Pt on IV Midamorphine 1mg/ml run 1 ml/H
R/Tube feeding Enercal 60 ml/H
CVL and artline intact
CBD functioning with hourly urine output monitoring
0800H
Eye care and mouth care done
Suction done with moderate thick blood stained(ett)and large thick yellowish(oral)
Medication served as ordered
ABG taken and recorded
0845H
S/B Dr Premalar and team
Change FIO2 to 0.4
Change IV Midamorphine to IV Morphine 1mg/ml after complete current infusion.

1000H
Repeat ABG done.Result noted to Dr Zohdy.No special ordered
1145H
V/O by Dr Premalar to change CPAP mode and 2 hourly positioning
1200H
Eye care and mouth care done
Suction done with moderate thick blood stained(ett)and large thick yellowish(oral)
Medication served as ordered
1300H
Repeat ABG done.
1400H
General condition pt remain same
Cont ICU management

Note Type : Nursing Report

Date/Time : 05/09/2013 10:17

Med/Anc Service : Anaesthesiology

Performed By : Nurulain Bt Ismail

Morning Shift
MOHD ASWADI BIN AB RAHMAN
DAY 6
DIAGNOSIS : ALLERGED MVA WITH SEVERE CHEST INJURY WITH MASSIVE
HAEMOTHORAX
TRO INTRAABDOMINAL INJURY
07.00 AM
General condition of patient concious but look weak
patient on GCS 11/15 E4 VT M6 and both of eye 3mm and reaction to light
ventilator setting CPAP mode , FIO2 : 0.3, PEEP : 8 , PS : 10
Vital sign AIBP : 123/63 mmHg , HR : 92 bpm , SPO2 : 100% , Temperature : afebrile
BP supported wih IV Noradrenaline 4mg/50cc D5% run 2ml/hr
patient on IV Morphine 10mg/ml run 2ml/hr
artline and CVL insitu
patient on RF Enercal run 60ml/hr continuous for 5hrs and 1hrs
CBD insitu for monitoring hourly urine output
08.00 AM
ABG taken and recorded
medication served as ordered
eye and mouth care done
suction done moderate thick yellowish secretion sucked out via ETT
While morning round with Dr Joshua :
reanchor ETT at 19cm
IV Mg SO4 10mmol/L - done
IV KHPO4 10mmol/L - done
09.37 AM
s/w dr Zurita

reanchor ETT (done) and repeat CXR - done

continue syrup lactulose
aim for extubation
cont rocephin
MgSo4 10mmol/l - given
KMnPo4 10mmol/l - given
Trace cultures
12.00 N
ABG taken and recorded
medication served as ordered
eye and mouth care done
suction done moderate thick yellowish secretion sucked out via ETT
CXR done, Dr Ashreena noted
review CXR by Dr Ashreena, no special order
Temperature : 38 , SPONGING stat
01.00 PM
Sponging done
bedsore Grade II seen
rowarolen powder apply
02.00 PM
General condition of patient remain same
all nursing care randed
continue GICU management

Note Type : Nursing Report

Date/Time : 05/09/2013 23:17

Med/Anc Service : Anaesthesiology

Performed By : Hiryanti Bt Khalid

Night Shift
DAY 6 IN ICU
DIAGNOSIS : ALLERGED MVA WITH SEVERE CHEST INJURY WITH MASSIVE
HAEMOTHORAX
TRO INTRAABDOMINAL INJURY
9.00pm
General condition of patient concious & alert but weak.
GCS 11/15 (E4, VT, M6 )and both pipils 3mm and reactive to light bilaterlly.
On ventilator setting with CPAP mode FIO2 : 0.3, PEEP : 8 , P/S : 10
Vital sign checked & recorded.
AIBP : 110/60 mmHg , HR : 90 bpm , SPO2 : 98% - 99% , Temperature : 37.3'C
BP supported wih IV Noradrenaline 4mg/50cc D5% run 0.2ml/hr
( To keep MAP > 65 mmHg )
Patient on IV Morphine 10mg/ml run at 2ml/hr - In progress.
Artline and CVL insitu
Patient on R/T Feeding Enercal run 60ml/hr continuous for 5hrs and 1hrs
CBD insitu for monitoring hourly urine output

12.00mn
All due medciation given as ordered - Charted.
ABG taken - Result up.
4.00am
All routine blood Investigation taken & despatced.
ABG taken - Result up
6.00am
All due medication given as odered - Charted.
Sponging done.
All dirty linen changed.
BNO.
Bedsore grade 11 seen at buttock - Coloplast was applied.
6.30am
Suction via ETT- Moderate blood stained secretion seen
- Good gag & cough reflex presented during suction.
7.00am
General condition of patient remain same.
All nursing care carried out.
Close observation continued.

Note Type : Nursing Report

Date/Time : 06/09/2013 14:14

Med/Anc Service : Anaesthesiology

Performed By : Rohana Bt Ibrahim @ Harun

Evening Shift
6/9/13
(DAY 7 IN ICU)
DIAGNOSIS : ALLERGED MVA WITH SEVERE CHEST INJURY WITH MASSIVE
HAEMOTHORAX
TRO INTRAABDOMINAL INJURY
2.00PM
General condition of patient concious & alert but weak.
GCS 15/15 and both pupils 3mm and reactive to light bilaterlly.
Nursed on prop up position,Breathing spontaneously via Ventymask 60% 12L/min.
Vital sign checked & recorded.
AIBP : 110/60 mmHg , HR : 90 bpm , SPO2 : 98% - 99% , Temperature : 36.5'C.
( To keep MAP > 65 mmHg )
Patient on IV Morphine 1mg/ml run at 3ml/hr - In progress.
Kept NBM due to post extubation @ 10.30am.
On IVD 1/5 D/saline 60 mls/hr in progress.
Artline and CVL insitu.
CBD intact with hourly urine output monitoring.
Pt for transfer out to ward 5C,awaiting ward.

4PM
Afebrile.Due medication served.Nebulizer ventolin given.
Restart feeding at 60 mls/hr in progress.
5.30PM
Pt B0X1,Large amount,loose stool.
Sore at sacral.Coloplast applied.
Pass over report to SN incharge SN Hasliana.
6.10PM
Due medication served.
Pt transfer out to ward 5C accompanied by SN Hasliana and PPK.
NIBP 126/56 mmHg,HR 72 bpm,RR 23 /min,spo2 100%.ECG monitor in sinus
rhythm.
All nursing care rendered.