Bed 5

AM review
Muhd Nur Aiman Zikri 13 yrs old
Malay, Malaysian
non trauma under Mr Lim
alleged
HOPI
C/O left foot swelling 1/52
Initially 3/52 ago on 3/5/15 patient played football and step on piece of glass on platar aspect of
left foot
this cause wound and bleeding
however pt claimed there is no piece of glass left in the foot
pt never seek any medical treatment and not take any antibiotics
1/52 ago pain and swelling develop over wound
initially on plantar aspect then swelling radiate to al toes and dorsum aspect of left limb
associated with redness of skin and collection over plantar aspect
otherwise
no fever
no SOB
no chest pain
no palpitation
no vomitting
past medical hx
nil
past surgical hx
WD over right thigh 2013
Allergy history
nil
Family
2 out of 3 siblings
mother 38, healthy
Social hx
Kota Puteri, Bestari Jaya
Live with mother
Study at SMK Raja Muda Musa
non smoker
not consume alcohol
denied high risk behaviour
O/E
alert
conscious
good pulse volume
hydration status good
vitals

bp 117/55
pulse 62
t 37
spo2 100%
lungs clear
CVS DRNM
abdomen soft non tender
Examination of left foot
swelling over plantar, toes and dorsum of left foot
fluctuant over plantar region
erythematous skin surrounding
warm and tender on palpation
able to move all toes
full ROM of Ankle
PTA and DPA palpable
CRT < 2 sec
sensation intact
Left foot x-ray : no obvious foreign body seen, no fracture seen
Imp : Left foot abscess TRO foreign body
Plan
for incision and drainage of left foot under LA OT
fluids
Allow orally
Medication
IV tramal 50mg TDS
T PCM 1g QID
IV cloxacillin 1g QID
Ix
FBC
other
informed Dr Syafiqah (HO PMOT)

----------------------------\
AM rounds
S/w Miss Linda, Dr Yaso
case and progress noted
plan
post case for I&D, removal foreign body under II under EMOT
NBM since 8am
IVD once NBM

Bed 6
AM review

Shafie Bin Mohamed , 45Y, Male

45 years old gentleman,
non trauma case under Mr. Nizam
underlying :
1/ DM > 10 years
on OHA
T. Metfromin 1G BD ( buy over the counter )
not on proper follow up
Imp: carbuncle of left leg
POD 1 Bedside saucerization of left anterior shin done under LA (in the procedure room)
by Dr Ki assisted by Dr Nadirah
findings
Drained out minimal pus ~3cc upon milking
material send
Tissue C+S and pus swab taken during the procedure
Progress
alert
concious
over the night comfortable
no active complaint
OE
Alert
Consious
not septic looking
pink
good pulse volume
crt< 2sec
vitals
T 37
BP : 136/ 80
PR : 88
examination left lower limb
bandage not soaked
able to move all toes
ROM ankle, knee and hip full
DPA/PTA palpable
sensation intact
CRT<2s
Plan
Fluids
Allow orally
Ix :
Medication

start IV unasyn 1.5g TDS

start sliding scale 2 , once NBM
T PCM 1 g QID
IV tramal 50 mg TDS
Others :
WI cm
Daily dressing with NS
to trace pus swab and tissue C+S
AM rounds
s/w Miss Linda, Dr Yaso
case and progress noted
WI : pus discharge, slough
plan
post case for WD of left leg under EMOT
NBm since 8am
start IVD

Bed 7
AM review
admitted in 5B from 13/5/15 till 16/5/15
Admitted in ICU from 16/5/2015 till 18/5/15
Mohd Yusuff Bin Mansor, 53Y
Malaysiasn Malay gentleman
Right Hand Dominant
Trauma case under Mr Gurjit
Underlying
1/ DM
2/ Hpt
3/ Dyslipidaemia
4/ IHD - had an episode of AMI last year
admitted in Hospital Temerloh
defaulted all treatment and follow up - on traditional meds
Alleged MVA (MB vs lorry) at 1pm 13/5/2015 at Kg Timah, Bukit Beruntung: PTD11
Under Ortho
1/ Open fracture midshaft left humerus, grade 3b
2/ Open fracture left radial head, grade 3b with left elbow instability
POD8 WD of left upper limb
on 16/5/2015,at 22:40-23:05H by Dr Hisyam and Dr Rathidevi
POD6 WD and cross elbow external fixator left elbow
done by Miss Norhaslinda, assisted by Dr. Yasothai, Dr. Hilmi (17:00-20:50H on 18/5/15)
Findings:

Open fracture midshaft left humerus, grade 3b

Open fracture left radial head, grade 3b with left elbow instability
radial nerve in continuity
Under Surgical
1/ right pneumothorax
2/ right lung contusion
3/ 3rd to 7th rib fracture with ? flail segment of 5th and 6th rib
- Right chest tube inserted on 13/5/15
- off on 16/5/15
-----------------------------------------------------------------------------------------------------------------Summary of presntation
had alleged MVA today when pt was riding from work at farm for lunch at 1pm
was not wearing helmet and does not have any valid licence
was riding a Kris 120cc at 30km/hr speed on a sandy road
suddenly his motorbike skidded and fell to the ground
Lorry which was behind him ran over his left hand
post trauma
pain over the left upper limbs and the back
could immediately sit up after trauma
+ SOB
no LOC
no vomiting
no ENT bleed
no chest pain/abd pain
Social Hx
lives with family
has 8 children
works as farmer
+ chronic smoker - 10 sticks per day for the past 30 years
no alcohol intake
-----------------------------------------------------------------------------------------------------------------Progress
comfortable
tolerating orally
no SOB, no chest pain
pain tolerable with analgesia
no acute complaints
O/E
alert, conscious
pink
warm peripheries
CRT < 2secs
good pulse volume
good hydration
vitals
T 37
BP 128/75
PR 83
Spo2 98% under RA
DXT 6.8

Left Elbow Examination

on cross elbow external fixator
CRT < 2secs
radial and ulnar pulse palpable
sensation intact
Plan
Fluid
allow orally as tolerated
Ix
Check Xray left humerus and elbow: reviewed acceptable
CT Left Elbow appt on 26/5/15, Tuesday, 11:30H
Medications
IV Cefuroxime 1.5g TDS D6
IV Tramal 50mg TDS
Tab PCM 1g QID
Tab Aspirin 100mg OD
Tab Plavox 75mg OD
Tab Atorvastatin 40mg ON
s/c Actrapid 8 unit TDS
S/C Insulatard 8 unit OD
Others
arm sling for comfort
for SSG later when patient more stable
to d/w family members regarding payment for ext. fix. deposit + shanz pin (under S&N)
dressing: daily NS+ bactigrass dressing over wound
APS TEAM PLAN (20/5/15)
off PCAF
cont oral analgesics
discharge APS
Plan
Plastic Surgical: wound closure
CT Elbow on 26/5/15, Tuesday
encourage incentive spirometry
chest physio
WI cm by plastic team- to call MO plastic oncall to review wound
DXT QID
Cont T Metformin 1g BD
Diabetic diet
ECHO outpatient appt- 2/9/15
PLASTIC TEAM PLAN (21/5/15)
- for Salcoceryl gel dressing, Bactigrass, packed with gaized and crepe bandages
Not for wound coverage yet - recipient bed not ready
TCA plastic 1 week
SURGICAL TEAM PLAN (21/5/15)
Off NP O2
No need to repeat ABG
Monitor SpO2

Encourage incentive spirometry

Continue ortho plan
AM rounds
s/w Miss Linda, Dr Yaso
case and progress noted
o/e
able to move all fingers
sensation intact
CRT<2s
plan
wound desloghing - done
intrisite gel dressing

Bed8
AM review
Tang How Kong, 30Y
Malaysian chinese male
Trauma case under Mr Nizam, Mr Faizal
NKMI
Dx:
Implant related infection with osteomyelitis of left femur
Curently, POD 17 for removal of implant, excision of left femur bone and illizarov ring
fixation done by Mr Gurjit assisted by Dr Hafiz, Dr Farid under GA from 1445 to 1800 on 7/5/15
Intraop findings:
necrotic bone
necrotic tissue
slough++
necrotic osteomyelitic bone removed 6cm
Tissue C+S on 7/5/15:
Enterobacter sp.
ANTIBIOTIC
Gentamicin 10
Imipenem 10
Meropenem 10
Doripenem
Ertapenem 10

SENSITIVITY
S
S
S
S
S

Bone C+S on 7/5/15:

Enterobacter cloacae
ANTIBIOTIC
Gentamicin 10
Imipenem 10
Meropenem 10
Cefepime 30
Doripenem
Ertapenem 10

SENSITIVITY
S
S
S
S
S
S

ESR trend:43-->0 --> 43 (17/5) --> 38

CRP trend:7.4-->3.2 --> 1.7 (17/5) --> 1.8
Gentamicin TDM level on 21/5/15: 0.04umol/L (within therapeutic level)
---------------------------------------------------------------------------------------------------------------------------------------------------Summary:
Alleged MVA (MB vs car) around 6.30pm 10/2/14 PT 1 year 3 months
sustained:
1/ Open Comminuted fracture Grade 3A LEFT supracondylar femur with intercondylar split
2/ Closed fracture distal end LEFT radius with LEFT ulnar styloid fracture (Frykman II) ==>
treated conservatively
3/ Superficial laceration wound at dorsum RIGHT index finger Zone 3
4/ LEFT posterior hip dislocation and LEFT knee dislocation (did CMR)
Underwent:
1) Wound debridement LEFT LL & Tibial Pin insertion done by Dr Murali, on 11/2/14
2) Wound Debridement and VA Locking Plate Distal LEFT Femur done under GA on 18/02/2014
by Mr. Nizam / Dr. Ramanand / Dr. Johny
3) Complicated with implant related infection of the right thigh (post distal femoral locking plate)
Post incision and drainage of left thigh done by Dr Khairul assisted by Dr Nur Amira on
20/10/2014
-----------------------------------------------------------------------------------------------------------------------------------------Pt riding Honda 100cc with valid license and fastened helmet
suddenly at a junction, unable to avoid a car that came from the left side
hit and fall with left knee hit the road first
unable to ambulate post trauma
Post trauma
no LOC
no ENT bleeding
no headache
no chest pain/ abdominal pain
----------------------------------------------------------------------------------------------------------------------------Progress
well
able to sleep last night
tolerating orally well
no active complain
O/e:
alert, conscious
pink
well hydrated
not tachypnoeic
not tachycardic
warm peripheries
vitals
T 37
BP 124/70
PR 88
Examination of left lower limb
on ilizarov fixator
dressing not soaked

sensation intact
Full ROM of ankle
DPA/PTA palpable
able to move all 5 toes
WI: noted 6 genta beads outside with minimal blood stain, inside 8
no pus / serous discharge
otherwise wound is clean
Check xray reviewed -acceptable
Plan
Fluid
Allow orally as tolerated
Medications
PCM 1g QID
Tramal 50 mg TDS
IV gentamicin 240mg OD D12
IV cefuroxime completed 5 days ( 8/5/14-12/5/15) --> Off already
Ix
weekly ESR/CRP/TDM genta/RP (next 24/5/15)
To keep Hb>8
To remove 3 gentabeads per day
To remove after round
Others
For daily WI and daily NS dressing over the wound and flavine dressing at pin site
reinforced bandage if soaked
TDM assessment and recommendation on 21/5/15:
Gentamicin level was 0.04umol/L which is within therapeutic range.
Suggest to continue current dose IV Gentamicin 240mg OD.
Kindly review duration of gentamicin therapy (Today D10).

Bed 10
AM REVIEW
Muhammad Suhail Bin Su'ib, 17 years old boy
Malaysian
Non trauma case under Mr Nizam
Underlying
1. cerebral palsy
-spastic paraplegia
-was diagnosed at 1year 6months old,with mental retardation
-under HKL follow up
2.CKD with neurogenic bladder - under urology HKL, Urea / creat baseline;4.3/86(in
sept 2014)
- on condom catheter
3. H/o Extensive wound debridement for fournier's gangrene 14/9/2014 and SSG on
17/10/2014 - for a fistulated ulcer
4. Defunctioning colostomy done in HKL in 2010

5. Sacral sore grade 4, healing, under plastics

6. Megaloblastic Anemia - folate and B12 deficiency
-under medical
Imp:
Osteomyelitis of proximal right femur and pelvis with pelvic, right hip and thigh abscess
Summary of presentation
DOA:17/4/2014 to plastic ward
Presented to ED with fever for 3/7,associated with LOA 1/52,nausea and vomiting
several times 2/7
On stoma bag cleaned daily ,using disposible stoma bag,good care
-->passing 3x soft stool + mucous no blood
CBD changed every 2 weeks - good nursing care at home
+ Bed sore since last year
- daily dressing done and every 2 weeks being reviewed by plastic team in HSgB
- site clean
- no pus discharge according to mother
-------------------------------------------------------------------------------------------List of operation done
Under Ortho
8/5/15: Girdle stone osteotomy of right femur, drainage of abscess, and wound
debridement of right gluteal wound
under GA on 8/5/15 from 12:25-13:30H done by Mr Nizam assissted by Dr Ki and Dr
Loh (POD16)
Pre-op Dx:
Right thigh abscess secondary to infected right gluteal sore, with osteomyelitis of
proximal right femur and pelvis
Post Op Dx:
Osteomyelitis of proximal right femur and pelvis with pelvic, right hip and thigh
abscess
Findings:
dislocated right femoral head into false right acetabulum
100cc pus from right hip, associated with friable and inflammed right hip capusule
and synovium
Osteomyelitis of femoral head up to proximal femur, also ilium
minimal sloughs at right gluteal wound, underlying ischium osteomyelitis, wound not
communicating to the pelvic cavity
Under Surgical
14/9/14: WD for Fournier Gangrene done by Dr Nitin
Under Plastic Surgery
28/4/15: Bedside debridement and exploration for Right greater trochanter sore
done by Dr Deva
17/10/14: WD + SSG for Post fournire's gangrene wound right inguinal extending to
right gluteal region done by Mr Syazli assissted by Dr Thomas and Dr Tan
-------------------------------------------------------------------------------------------Progress

Comfortable
no fever
no SOB/chest pain/palpitation
mild pain over op site
good oral intake
no active complaints
On examination
Alert
clinically pink
not tachypneic
CRT<2s
Good hydration
Warm peripheries
good pulse volume
Vital signs
HR 109
BP 110/64
T 37
WI over right thigh
dressing not soaked
wound clean, no active bleeding
---> daily NS dressing
WI over sacral sore
clean
---> daily Povidone dressing
------------------------------------------------------------------------------------------------Investigations
initially presented to ED on 17/4/15 (current admission)
FBC WCC 12.1/ Hb 5.6/ HCT 18.2/ / Plt 304
CRP (23/4/15): 24.5
ESR (27/4/15): >140
Inflammatory markers trend
WCC 8.26 -- 18.49 -- 14 -- 17.33 -- 13.88 -- 13.29 (April) -- 15.22 -- 20.54 -- 27.05
--15.54-10.8 (18/5/25)
CRP 21.2 -- 7.1--18.1 (17/5)
ESR > 140 -- 100 --98 (17/5)
Hb 10.6--10.4 (18/5/15)
10/5/15
RP Ur 5.9/ Na 139/ K 4.2/ Cr 74.3
TP 64/ TB 4.1/ Alb 12/ ALP 205/ ALT 21
Culture and Sensitivity
Pus C&S (18/4/15): Mixed growth of 4 types of organisms isolated
Pus C&S (27/4/15): Bacteroides eggerthii
- Sensitive to Imipinem, Tazobactam, Clindamycin, Metronidazole
- Intermediate: Ampicillin

Pus C&S (8/5/15): ESBL

Tissue C&S (8/5/15)
Gram stain: numerous pus cells seen,occasional gram -ve rods seen
Tissue C&S (8/5/15): Enterobacter sp ESBL sensitive to Augmentin,
Ertapenem, Meropenem, Gentamicin
Resistance to Ampicillin, Cefuroxime, Cefepime, Cefazolin
Body Fluid C&S (8/5/15)
Gram stain: numerous pus cells seen, no organism seen
Macroscopic appearance: grossly blood stained
Cell count: not suitable
C&S: Mixed growth of 2 types of gram negative and 1 type of grampositive
Urine C&S (18/4/15): Proteus sp (Sensitive to Amikacin, Cefepime)
Urine C&S (1/5/15): No growth
Stool C&S (21/4/15): No growth
Blood C&S (19/4/15): NGD5
Blood C&S (24/4/15): NGD5
Blood C&S (27/4/15): Staphylococcus, coagulase negative (Doubtful clinical
significant)
WI: +slough, minimal foul smelling
Dato' Haji Zamyn Zuki mentioned during X-ray Conferences on 8/5/15
- if there is a collection of abscess in the pelvis that requires drainages, KIV refer to
Dato' Yusof
case and progress updated to Mr Nizam (Specialist incharge) on 15/5/15
- noted that Plastic Surgery team already disharged the pt
- allow t/o to ISO 5A if bed available
- KIV refer HTAR Surgical/ HKL Ortho later
case discuss during xray conference today with presence of Mr Lim, Ms Linda
plan to continue IV abx
weekly CRP/ ESR
CT Abdomen/Pelvis 21-05-2015
Previous CT of 30-04-2015 has been reviewed.
Findings:
Interval right girdlestone procedure.
Right femur is dislocated posteriorly - unchanged
Multiple gas pockets noted at the residual proximal femur.
Size of right iliacus collection is smaller in size, measuring 0.8 x 3.1cm ( AP x W )
( Previously 2.5 x 4.6x 7cm) with gas within.
Diffure fat stranding in the right gluteal and obturator regions with residual smaller
collections. Gas pockets are present within.
Collection in the upper thigh muscles are largely unchanged in size. There is
increased gas within these collection.
Increased cortical destruction in the right ischium with presence of gas pockets.
Focal area of the right ischial tuberosity is deficient of subcutaneous tissue or muscle

superficially.
Left femur remains dislocated. The collection in left hip joint and gluteal region are
larger in sizes. No gas pockets.
Lymphadenopathy in inguinal, iliac bilaterally, aorto-caval and para-aortic regions.
No intra-abdominal collections present.
Colostomy as noted previously. The rest of the bowels are normal in appaerance.
Urinary bladder is enlarged with serrated outline. Bilateral hydroureter and
hydronephrosis have increased in degree of dilatation.
No radiodense calculus.
Ascites is present.
Hepatosplenomegaly as noted before.
Included lung bases are normal.
Coccyx is deficient. No significant bone erosion or destructive lesion seen in the rest
of the bones.
IMPRESSION
1. Interval right girdestone procedure. Residual collections in the right hip and thigh,
and left hip as detailed.
2. Osteomyelitic changes in the right proximal femur and ischium.
3. Increased hydronephrosis and hydroureter bilaterally.

ECG 23/5/15: sinus tachycardia

Plan
Fluids
Allow orally
IVD 1 pint NS maintenance
Medications
IV ertapenem 1g od -- > started on 19/5/15 ( D5)
IV Meropenem 1g TDS ( 14/5 -19/5/15)
IV Tramal 50mg TDS
Tab PCM 1g QID
Tab Ferrous Fumarate 400mg OD
Vitamin B complex 1 tab OD
Multivitamin 1tab OD
Investigations
Inflammatory markers weekly (FBC/ CRP/ ESR): due on Monday, 25/5/15
Others
Close V/S monitoring
daily dermasyn was followed by NS dressing over right thigh wound
daily Povidone dressing over sacral sore
I/O charting
STO D14 (22/5/15)--> done
KIV refer HTAR Surgical/ HKL Ortho later ( to d/w Mr Nizam)
MEDICAL TEAM PLAN (19/5/15)
high protein diet
off meropenem
change to IV ertapenem 1g OD for 1week

CT pelvis on Thursday
PLASTIC SURGERY TEAM PLAN (13/5/15)
Discharge from plastic surgery (no active management)
TCA plastic clinic 1/12
Continue ortho management

To discuss CT pelvis in xray conference