General Clerking Note

Location :EDRZ

S/B Dr.Ang SH
Patient's current condition and update informed and explained to daughter and
granddaughter
explained that his current condition is critical and might deteriorate further
We will provide symptomatic treatment and in the event of cardiac arrest, will not
proceed with CPR and inutbation
Both daughter and grandaughter understood and agreed for NAR

daughter- Pn Kamisah binti Jamil

IC 591025-01-5944

Grandaughter - Norizanani binti Mat

IC 840929-01-6282
89yo malay gentleman
history from patient's daughter (caretaker)
ADL fully dependent since July 2018 due to CVA
Bed bound since July 2018
Underlying
1. HPT
2. AF (poor candidate for warfarin)
- CHADVasc 5 ( HTN, age, hx stroke)
3. CVA with right-sided hemiparesis
- on RT Feeding
- since July 2018
4. BPH
- Under SFUC f/up
- CBD 2 weekly change, planned for US KUB and pelvis (scheduled on 28/10/18)

5) Peptic Ulcer Disease

OGDS findings (26/8/2018)
Single oesophageal tear above COJ , clean base
Multiple healed ulcer at prepyloric
Forrest 3 ulcer at D1/D2 with duodenitis & erosion
Biopsy: CLO positive
Endoscopic impression:
Mallory's weiss tear
Peptic ulcer disease

Homemeds:
T. Bisoprolol 2.5mg OD
T. Ranitidine 150mg OD
T. Aspirin 150mg OD
T. Simvastatin 40mg ON
T. Cardura 4mg OD
CC
brought in by grandaughter for RT Insertion

HOPI
patient is a k/c/o CVA with right sided hemiparesis on RT Feeding, 2 weekly
change

claims RT was pulled out by patient since 1week ago,

came for RT insertion in edgz on 13/9-however RT Insertion unsuccessful as
patient was uncooperative
discharged

claims tried RT insertion in KK after that, hjowever still failed

brought in today for RT insertion

also gives c/o no oral intake since then, i/v/o no RT

family members have been giving him water by mouth, claims patient has cough
everytime gives water

otherwise
denies fever
no abd pain
no vomiting
no diarrhea
On examination
alert
E4V2M6(baseline)
good PV warm peripheries
fair hydration

Vital Signs
BP 122/81
HR 71
T 36.5'C
SPO2 97% under RA
GM 9.7mmol

Lungstransmitted sound, reduced air entry left LZ

CVS DRNM
PA soft

Investigation
FBC minilab
WCC 14.8
Hb 14.5
PLT 234

RP 17/9
Na 155
K 5.3
Ur 28.5
Cr 235
Ca 2.5
PO4 2.2
Mg 1.3

CE 17/9
CK 61
LDH 292

ABG NP3L
pH 7.37
pCO2 31
pO2 153
HCO3 17.8
BE -6.1

CXR clear, no cardiomegaly

ECG AF with rapid fast ventricular response, HR 170/min
ECG post digoxin AF HR 123/min
Treatment in ED
IV Digoxin 0.5mg in 100ml NS over 1 hr
Impression
1. Orthostatic pneumonia
2. AF with rapid ventricular response
- CHADVasc 5 ( HTN, age, hx stroke)
- HASBLED 3 (abnormal kidney fx, age, previous stroke )
3. AKI 2' to 1
Plan
Admit 7A
VS monitoring 4hourly
GM QID
keep SPO2 > 95%

Start IV Rocephine 2g STAT and OD

T. Bisolvon 8mg TDS
IVD 4pint 2HS2D5/24H
SC Actrapid 6U PRN if GM > 12mmol

Cont Home medication

T. Bisoprolol 2.5mg OD
T. Ranitidine 150mg OD
T. Aspirin 150mg OD
T. Simvastatin 40mg ON
T. Cardura 4mg OD

Send FBC, Blood C+S , ESR . CRP, serum Mycoplasma

Daily RP

Refer Chest and limb physiotherapy

Dietician to start RTF in ward.