CASE WRITE UP

ANAESTHESIOLOGY POSTING

Name : SANGARI A/P R.SARKUNA SINGAM

Student ID : 1001439079

Year 4 , Group 1

Date : 21/ 1/ 2016

Patients Details

Name : Sakinah Binti Muhammad

Age : 51 years old
Registration number (RN) : HSNZ00521854
Race : Malay
Religion : Muslim
Marital status : Married
Occupation : Housewife
Date of admission : 16/1/2016
Date of clerking : 19/1/2016
Place of clerking : Ward 4A (PRIBA)

History / Pre-op assessment

Chief complaint
Patient presented with lethargy and dizziness for 2 weeks and shortness of breath on the day
of admission.

History of presenting complaint

Patient was apparently well until 2 weeks ago when she gradually found herself to get tired
easily and felt like she did not have the energy to carry out her daily activities as before. Even
doing light housework like sweeping and washing plates was becoming a strain to her but she
however only took rest in attempt to alleviate the tired feeling. Besides that she also felt dizzy
at times and would have to sit and rest before she continued with her activities. These
symptoms manifested as she was having heavy menstrual flow which seem to have prolonged
up to 2 weeks with heavy flow on the first 6 days as she had to change fully soaked pads
about 5 to 6 per day. The heavy menstrual flow is also associated with dysmenorrhea but she
denied having any intermenstrual bleeding, postcoital bleeding or dyspareunia. Normally her
menstruation is for 6-7 days out of 35 days cycle and is regular with the usual heavy flow for
the first 3 days and gradually becoming lesser the remaining days. But since a year ago,
patient has been experiencing similar problems with her menstruation as the one she is
having now although her symptoms seem to have been somewhat tolerable until this episode
in which when she developed muscle ache along with her constant feeling of lethargic and
had shortness of breath on the admission when she was doing her prayers in the morning. She
was then immediately brought to the emergency department where she was found to be
anemic as her hemoglobin level was 8.9 g/dL and she was then given blood transfusion. A
few other investigations were carried out like chest x-ray and ECG which revealed to be
within the acceptable range and she was then reviewed by the doctor and was scheduled for
hysteroscopy and dilation and curettage on the 17/1/2016 as she was suspected to have
submucosal fibroid in her uterus that is causing the menorrhagia. A day before her operation,
she was asked to fast and so patient had her last meal at 2am before her scheduled operation
at 11 am the next day.

Systemic review
1) General: absence of fever, no loss of appetite, no weight loss, no sleep disturbance
2) Cardiovascular system: absence of chest pain, palpitations, orthopnea, and paroxysmal
nocturnal dyspnea
3) Respiratory system: presence of shortness of breath but no coryzal symptoms or cough
4) Nervous system: No headache, no syncopal attacks, blurring of vision, weakness or
numbness of the extremities, and no increased tone of muscles
5) Urinary system: absence of polyuria, no nocturia, no hesitancy,no poor stream of
urine, presence of dysuria, unsatisfactory voiding and increase in frequency
6) Gastrointestinal system: absence of diarrhea, presence of constipation, painful
decation, nausea, vomiting,
7) Musculoskeletal system: presence of musche ache but no bone and joint pain

Menstrual & gynaecological history

She achieved menarche at 12 years old. All the other relevant details about her menstruation
has already been mentioned. Her last menstrual period was last month on 30th of dec 2015.
She has never done a pap smear before.

Past obstetrics history

Patient has 4 children, 2 boys and 2 girls, aged between 12 and 20. All of them were born via
a normal delivery and she did not have any complications with all her pregnancies.
Previous operation and anaesthesia history

Patient has underwent an operation before at the age of 35 for the removal of thyroid cyst
under general anesthesia. Detailed information regarding the anesthesia could not be elicited
from the patient or her medical records although the patient claimed that she was fine after
the surgery and did not developed any complication due to the surgery or anesthesia used.

Past medical and present medical condition.

Patient claims that she does not have any medical illness. She has history of chronic medical
illnesses such as hypertension, diabetes mellitus, heart disease, respiratory disease or renal
disease .

Family history

Her parents are both alive. Her father was diagnosed with hypertension 20 years ago and her
mother was diagnosed with diabetes mellitus 10 years ago. Beside that they have no known
problems related to surgery or anesthesia or any other medical illnesses such as heart disease,
inherited blood diseases or malignant hyperprexia.

Drug, diet and allergy history

She has been prescribed with tranexamic acid (250 mg), iron dextran and sucrose. But other
than that she denies taking any over the counter including oral contraceptive pills (OCP) or
traditional medications. She eats the usual balanced Malaysian diet. She does not have any
known drug and food allergies.

Social history

Her educational level is up to SPM. Her husband is 57 years old, owns a restaurant and is in
good health. She is currently living with her husband and her 4 children at a comfortable
house with all the basic amenities at Marang. She does not smoke but her husband smokes
about 20 pack years. Both do not drink alcohol or use intravenous drugs.
Physical Examination

General examination
The patient was comfortably lying supine on the bed with one pillow under her head. She was
conscious, cooperated, alert and was not in any respiratory distress or there were no signs of
anemia or jaudice. There were no drip lines, branula or any medical apparatus attached to her.

The patients nutritional and hydration status was normal.

Weight : 69 kg
Height : 159 cm
BMI : 27.3 kgm

Vital signs
Respiratory rate: 20 breaths/min (normal)
Pulse rate: 80 beats/min (normal volume and regular rhythm, collapsing pulse not present)

Temperature: 37 C

Blood pressure: 133/80 mmHg (slightly above the normal range)

Pain score: 0 out of 10

On examination of the hands, her hands were warm and dry. There was no pallor of the nail
beds,no peripheral cyanosis, clubbing, koilonychia or palmar erythema. Capillary refill time
was less than 2 seconds.
On examination of the face, there were no facial abnormality and her conjunctiva was pink
and her sclera was white. No xanthelasma, and no corneal arcus can be observed. The
mucous membrane of the oral cavity was moist and no central cyanosis, glossitis or angular
stomatitis.
As for the examination of the neck, no thyroid or lymph nodes mass were palpable however
there was a well healed scar with no sign of inflammation or discharge on the left side of the
thyroid measuring 4 cm.On examination of the lower limbs, there was no pedal edema at her
legs, calf tenderness was not present and no varicose veins seen.

Cardiovascular System : First and second heart sounds (s1 and s2) were heard, apex is
located at the 5th intercostals space midclavicular line,no heaving, thrills or thrusting felt.No
murmurs or other abnormalities detected.
Respiratory examination : Patient had the normal vesicular breath sounds, air entry was
equal on both sides with no added sounds such as crackles and no sign of pleuaral effusion.
Upon percussion there was no difference on both sites. Vocal fremitus and vocal resonance
are equal on both sides.

Central Nervous System : High mental function, cranial nerve, motor and sensory nerves
are intact.

Musculoskeletal System : There were no gross abnormalities or discolored skin seen at the
trunk or extremities and the range of motion of all the joints seem to fine.

Airway and Risk Assessment :

- Mallampati Score : Class I
- Thyromental Distance : > 4 fb
- Any Neck abnormality :
-Interdental Gap : > 3 fb
- ANA Score : II
- Glasscow Coma Score : Eye response ( 4), Verbal Response ( 5), Motor Response ( 6)
Total : 15

Summary : Sakinah binti Muhammad, a 51 year old housewife came with complaint of
lethargy and dizziness for 2 weeks and shortness of breath on the day of admission. She has
been experiencing heavy menstrual flow with dysmenorhea for more than 2 weeks before
experiencing these symptoms. Physical examination was normal.

Provisional Diagnosis : Anemia secondary to menorrhagia

Special Investigations done for this patient at HSNZ :
1) Full blood count :
Blood Components Values Interpretation
Hemoglobin( Hb) 8.9 g/dL Low
Platelets 466 x 10^9/L Increased
Total White blood 8x 10^9/ L Normal
Count

2) Electrocardiogram :
Showed T inversion at lead V1, V2 and V4.

3) Chest X-ray : Normal.

Re-checking of necessary details before surgery

Patient's consent has been obtained from this patient prior to her operation and she has been
informed of the procedure that is going to be carried out and the possible complications. She
was not given any pre-medications as she did not have any indications for it. She has also
fasted for 8 hours and her last meal was 2 am this morning.

As there is a risk of blood loss in this procedure, GSH ( group save and hold) has been
prepared for this patient.

All the details that identifies the patient has been checked for the last time.

Intraoperative Management

Name of procedure done : Hysteroscopy with dilatation and curettage.

Patient was brought into the operation theatre around 11 am. All the necessary equipments
was attached to the patient, this included the ECG, pulse oximetry, capnography and BP cuff.
An intravenous access was secured before doing the lumbar puncture.She was then placed in
a sitting position and asked to hug a pillow so that the spinal area is more prominent. The
anesthesiologist then palpated the area that is favorable to insert the needle, disinfect the skin
using alcohol swabs and then put drapes on the patient's back with a rectangle hole showing
only the area that the spinal needle is to be inserted. A local anesthetic was injected first
( fentanyl) before giving the spinal anasthesia. The patient was then tested for sensation on
her lower limbs. Hysteroscopy was done following that.
Technique of anaesthesia in this patient : Spinal anaesthesia

Medications given : Heavy Marcain 0.5 % (Bupivacaine) with 30 mcg Fentanyl ( mL)

Needle used : Pencan 27 G

Specimen collected : Endocervical polps ( Sent for histopathological evaluation)

The whole procedure took a duration of 1 hour and so it ended around 12.10 pm.

Post- operative Management

Patient was conscious and alert after the operation and was given haartman solution. She was
placed at the recovery area for about 30 minutes before being taken back to the ward.

Her vital signs at the recovery area :

Blood pressure : 116/ 68 mmHg

Heart Rate : 65 beats per minute

Temperature : 37 c

SpO2 : 100 %

Pain score : 0 out 10

Patient said that the numbness at her lower part of her body gradually disappeared about an
hour after the operation and she was able to move her legs and fell sensation after that.
Patient had to stay in the hospital for about 4 days before being discharged for monitoring of
her condition. Patient had back pain, felt dizzy and had a headache a few hours after the
procedure and was given NSAIDs for it and was told to take bed rest. Other than that she did
not experience any complications like hemorrhage, fever following the procedure and was
discharged well.