M.

Kandiah Faculty of Medicine and Health Sciences, UTAR

Score sheet for CASE Write-Up
ANAESTHESIOLOGY
Year 4 MBBS

Student Name: Deipan A/L Arjunan

ID No. 20UMB03886
Name of Lecturer: Dr Huda binti Zainal Abidin

Clear report on anaesthetic procedure

Chief complaints
History chronologically clear with relevant
positive & negative findings, systemic
review, personal & social history (i.e birth,
nutrition, vaccination, etc)
3/5 in the operating theatre 7/10
Report on progress of patient and
12/20 monitoring data during operation 7/10

Physical Examination findings are clearly

and comprehensively documented, with
12/15 Post-operative final diagnosis 3/5
relevant positive and negative findings
included

Summary of case clear & concise
Clear & logical discussion of
diagnosis/Differential diagnosis, supported
by clinical evidence
Post-operative anaesthetist’s
3.5/5 instruction for post-operative room 3 /5
Clear & critical discussion of case
(learning issues, evidence-based
6/10 management, prognosis and ethical 8/10
issues of this patient,
professionalism)

Investigations performed in the surgery

67.5/1
ward and appropriate indications, and type 3/5 Total score
of surgery 00

Signature of Lecturer: Huda Date: 20/01/24

 PATIENT IDENTIFICATION

Patient’s initials: Mr. T R/N:AM856072 Age: 26

Gender: Male Ethnic group: Indian

Date of admission to Hospital :27/12/2023

Date of discharge from Hospital: 29/12/2023

Date of clerking: 28/12/2023

Source of History: Patient

Chief Complaint
Mr T, a 26-year-old Indian man, came in for an elective surgery for dynamic compression
plate (DCP) for left radius and ulna.

History of Presenting Illness (HOPI)

Mr T was apparently well until 1 month before admission, when he was the rider of a
motorcycle around 9 am on the way to work. He was wearing a buckled helmet. The
motorcycle skidded and the speed was around 50-60 km/h. He fell on his left side and
tumbled.
He then noticed a deformity of his left distal forearm after the trauma. It was associated
with a single large swelling around the distal 3rd of his left forearm which progressively
increased in size over time. There was pain which was sharp in nature. The pain was localised
to the site of injury, and it increased in severity over time up to the pain scale of 10/10 which
was severe pain. The pain was worsened by even slight movement of his left forearm and
wrist. No relieving factors during the time of accident but in the ward, the pain was relieved
by oral analgesics. After the incident, he was unable pronate or supinate his left forearm and
movement of the left wrist join was limited due to the pain, but he could still move his left
shoulder, elbow, and all fingers. He did not suffer any wound on the site of deformity, chest
or head trauma, dizziness, vomiting, memory loss or excessive sweating, neurological
changes. After the accident, Mr T was brought by his friend to the emergency department. X-
ray of ulnar and radius were taken and closed manipulative reduction of left forearm with
backslab was done in the emergency department.
Systemic Review

General Health No fever, no chills/rigors, no night sweats, no fatigue, good

appetite, no sleep disturbance.
Musculoskeletal As mentioned in HOPI. No joints or muscle pain.
System
Cardiovascular No orthopnea, no paroxysmal nocturnal dyspnea, no cold hands or
System feet, no leg edema, no intermittent claudication, no palpitations
Respiratory System No hemoptysis, no wheezing, no shortness of breath, no cough
Gastrointestinal No oral ulcers, no dysphagia, no nausea or vomiting, no altered
System bowel habit, normal stool color
Genitourinary No dysuria, no polyuria, no nocturia, no hematuria, no urinary
System incontinence, no hesitancy, no poor stream
Neurological No headaches, no dizziness, no seizure, no visual disturbance, no
System weakness of his arms & left leg, no numbness/tingling of his arms
and left leg.
Hematological No easy bruising, no bleeding tendency, no skin rash
System
Endocrine System No hand tremor, no heat or cold intolerance

Past Trauma/Accident history

No previous trauma or accident history

Past Medical and Surgical history

No previous medical or surgical history.

Drug and Allergy history

Mr T did not take long term drug or medications in the past. Mr S has no known drug or food
allergies. He has no environmental allergies.

Diet History
He usually takes 3 main meals per day with regular meal timing. He describes his diet as
typical Malaysian diet, and he is not a picky eater.

Family History
Mr T is the eldest child. He has a younger sister. His father, mother and sister are still healthy
and well without known comorbidities. There is no malignancy or known family-inherited
diseases within the family.

Social History

He is currently living alone in Pandan Indah in a single storey terrace home. His house is
furnished with sitting toilet. He is right hand dominant. Mr T is an ex-smoker and stopped 2
months ago. He does not drink alcohol and has never been involved in any form of illicit drug
usage. He is a currently working as a electrical technician.

PHYSICAL EXAMINATION
Anthropometric Measurement

Height : 163 cm
Weight : 96 kg
BMI : 36.13 kg/m2
Normal range : 18.5 - 24.9 kg/m2
Interpretation : Mr T is within obesity class II BMI range.

VITAL SIGNS ON ADMISSION

Vital Sign Range Value Interpretation

Pulse rate (beats per minute) 60 - 100 75 Normal

Respiratory rate (breaths per minute) 12 - 20 16 Normal

Blood pressure (mmHg) 90/60 - 140/90 137/95 Diastolic Hypertension

Temperature (℃) 36.1 - 37.2 36.7 Normal

SpO2 (%) under room air ≧95 100 Normal

General Examination
Upon examination, Mr T was sitting comfortably on the bed. He was alert, conscious and
cooperative and well-orientated to time, place, and person. There was no signs of respiratory
distress or anxiety. Upon checking the surrounding, there was a backslab on his left forearm
as well as an IV line attached to the dorsum of his right hand. He did not appear toxic or
extremely ill-looking. He looked to be overweight, and there were no signs of dehydration as
his skin turgor was intact and there was moist lips and mucous membrane, tongue and no
sunken eyes could be appreciated.

On examination of Mr T’s face, no dysmorphic facial feature could be appreciated.

This was no pallor and yellow discoloration of the sclera. There was no nasal discharge,
mouth was moist, and tongue is not centrally cyanosed. There were no angular stomatitis or
glossitis. Oral hygiene was good as his gum looked healthy without dental caries noted.
 Upon checking Mr T’s neck, there were no scars, swelling or lumps, dilated veins
visible. Carotid artery pulsation was palpable and there was no carotid bruit. There was no
thyroid enlargement appreciated.

Upon general inspection of his upper limbs, his left forearm was in a backslab. His
left upper limb was in normal neutral position. Right arm’s texture was good. Otherwise,
there were no scars, scratch marks, skin discoloration noted. Both hands were not pale and
warm to touch. There was no palmar erythema, Osler nodes, Janeway lesion noted on his
palms. There were no signs of thenar muscle wasting or Dupuytren contractures noted. There
was no acanthosis nigricans noted over axilla regions and the back of his neck. His capillary
refilling time was less than 2 seconds. Radial artery pulsation was palpable with good volume
and regular rhythm. There was no leukonychia or koilonychia, no tar-staining nails and
Bouchard’s nodes, Heberden's nodes. There was swelling noted on his right upper limb with
visible enlargement compared to the left upper limb. Otherwise, no other deformities
detected.

On examination of cervical lymph nodes, there was no submental, submandibular,

parotid, preauricular, posterior auricular, occipital, supraclavicular, infraclavicular, anterior
and posterior deep cervical lymph nodes palpable. Axillary lymph nodes were not palpable as
well.

Musculoskeletal Examination

Upper limb examination (Elbow and wrist joint)

Attitude:

o Unable to assess left upper limb due to left forearm in backslab

o Attitude of right upper limb is normal

Inspection:

o Patient was positioned in a sitting position.

o Both of his upper limbs were adequately exposed up to his shoulder.
o No muscle wasting was seen in this patient.
o There was obvious diffuse swelling over the wrist area which was not covered by the
 backslab
o Otherwise, right upper limb was in neutral position with no deformities noted. There
were no scars, involuntary movements or fasciculation, no open wounds, no bruises,
or skin discoloration seen over both his upper limbs (apart from the left forearm
which was covered by backslab).
Palpation

Right Forearm Left Forearm

● Normal temperature ● Localised rise in temperature of the

● No tenderness on palpation overlying skin of the right wrist
● Tenderness on palpation over backslab

Right Elbow Joint Left Elbow Joint

● Normal temperature ● Normal temperature

● No tenderness upon palpation of radial ● Could not be palpated to pain and
head, radio capitellar joint, lateral backslab
epicondyle of the humerus, olecranon,
medial epicondyle of the humerus and
biceps tendon

Right Wrist Joint Left Wrist Joint

 Normal temperature ● Cannot be palpated due to pain and

 No tenderness upon palpation of backslab
metacarpophalangeal joint (MCPJ),
proximal interphalangeal joint (PIPJ),
distal interphalangeal joint (DIPJ),
carpometacarpal joint (CMCJ) of the
thumb and anatomical snuffbox
**Red circle indicates the site of pain
Range of Movement

Right Left (Affected side)

Elbow Joint
Active Passive Active Passive

0-145˚ 0-145˚ Not assessed due Not assessed due

Flexion
to pain to pain

0˚ 0˚ Not assessed due Not assessed due

Extension
to pain to pain

0-85˚ 0-85˚ Not assessed due Not assessed due

Pronation
to pain to pain

Not assessed due Not assessed due

Supination 0-90˚ 0-90˚
to pain to pain

Interpretation:

Range of movement was only done on unaffected right elbow and there was no restriction in
range of movement.

Range of Movement

Right Left
Wrist Joint
Active Passive Active Passive

0-90 ˚ 0-90 ˚ Not assessed due Not assessed due

Flexion
to pain to pain

0-90 ˚ 0-90 ˚ Not assessed due Not assessed due

Extension
to pain to pain

0-15 ˚ 0-15 ˚ Not assessed due Not assessed due

Radial Deviation
to pain to pain

0-45 ˚ 0-45 ˚ Not assessed due Not assessed due

Ulnar Deviation
to pain to pain

Interpretation: Full range of movement of right wrist joint, movements of left wrist joint were
not assessed due to patient’s complaint of pain.
Special Test (For right unaffected wrist and elbow Joint) ** Was only done on
unaffected right upper limb, left upper limb wasn’t done due to pain.

Special test Findings Interpretation

Tinel sign Negative No carpal tunnel syndrome

Tennis
Negative No medial epicondylitis
elbow

Golfer elbow Negative No lateral epicondylitis

Neurovascular Examination

NEURO Right upper limb Left upper limb (affected side)

SENSORY

Crude touch Intact Intact

Fine touch Intact Intact

Proprioception Intact Intact

Vibration Intact Intact

MOTOR

Power • Elbow flexion: 5/5 Unable to assess due to pain

• Elbow extension: 5/5
• Wrist Extension: 5/5
• Wrist Flexion: 5/5

Reflex • Triceps reflex: intact Unable to assess due to pain

• Biceps reflex: intact
Supinator reflex: intact

VASCULAR

Radial Palpable with good volume Palpable with good volume

CRT < 2 secs in all 5 fingers < 2 secs in all 5 fingers

 Allen Test Normal Unable to assess

Interpretation: Neurovascular examination of left upper limb was not able to be assessed due
to pain. Otherwise, right upper limb showed normal intact sensory and motor function.
Vascular system for both upper limbs were good with normal CRT of the fingers and radial
pulse were all palpable with good volume for both upper limbs and Allen test was normal for
the right upper limb.

Peripheral nerve examination

Nerve Component Right Upper Limb Left Upper Limb (affected side)
Axillary nerve Sensory No sensory deficit on the Unable to assess due to pain
lower part of deltoid
Motor The power of shoulder Unable to assess due to pain
abduction was 5/5
Musculocutaneous Sensory No sensory deficit over lateral Unable to assess due to pain
Nerve aspect of the forearm
Motor The power of elbow flexion Unable to assess due to pain
was 5/5
Radial Nerve Sensory No sensory deficit over Unable to assess due to pain
posterior compartment of
arm, forearm, lateral 2/3 of
dorsum and proximal dorsal
aspect of lateral 3 ½ fingers
Motor The power of elbow extension Unable to assess due to pain
was 5/5
Median Nerve Sensory No sensory deficit over the Unable to assess due to pain
skin over thenar eminence,
lateral 2/3 of palm, palmar
aspect, and dorsal fingertips
of lateral 3 ½ fingers.
Motor The power of thumb Unable to assess due to pain
abduction was 5/5
Ulnar Nerve Sensory No sensory deficit over the Unable to assess due to pain
skin over hypothenar
eminence, medial ⅓ palm of
 hand, palmar aspect of the
medial 1½ fingers, medial ⅓
dorsum of hand and dorsal
aspect of medial 1½ fingers
Motor The power of finger Unable to assess due to pain
abduction was 5/5
Interpretation: There were no abnormalities in the unaffected right upper limb, the left
upper limb could not be assessed due to the pain the patient was experiencing

Cardiovascular Examination

Upon hands inspection, there was no clubbing of fingers, leukonychia, koilonychia,

Janeway lesion, Osler’s node, or splinter hemorrhage. There were no peripheral cyanosis and
both hands were warm to touch Radial, brachial, carotid, and dorsalis pedis pulse can be felt
symmetrically on both sides. Radial pulse was 72 beats/minutes, good volume, character with
regular rhythm. There were no collapsing pulse and radial-radial delay. On inspection of the
face, there were no xanthelasma, no rash, pallor, or jaundice. No distended neck veins noted
and both carotid pulses were palpable with regular rhythm without carotid bruits heard over
stethoscope auscultation.

On inspection of the lower limbs, there were no varicose veins and no ankle oedema
noted. Both dorsalis pedis and posterior tibial pulse were palpable in both lower limbs with
good volume and character.

On inspection of the chest, chest was symmetrical on both sides, and it moves with
respiration. There were no scars or chest deformity, no precordial bulging, and no visible
pulsation. Apex beats can be felt at the left 5 th intercostal space at the midclavicular on
palpation which is therefore not displaced. There were no heaves or thrills felt over the
parasternal area and precordium. On auscultation, there was normal dual rhythm (S1 and S2)
heart sound with no murmurs heard over mitral, tricuspid, pulmonary and aortic valves.
Respiratory Examination

The patient had no signs of respiratory distress, cyanotic features nor dyspnoeic.
There was no apparent usage of accessory breathing muscle (sternocleidomastoid/ indrawing
of abdominal muscle). Respiratory rate was 16 breaths per minutes. On chest inspection,
there was no trauma/surgical scars. Breathing pattern was normal and the chest move with
respiration symmetrically. No audible wheezing was heard when respiration. Upon palpation,
chest expansion and tactile vocal fremitus were equal on both sides. Upon tracheal palpation,
tracheal position was not deviated as it was centrally located and no tracheal tug. On
percussion, there was normal resonance sound heard over anterior and posterior lung fields
except for cardiac and liver dullness. On auscultation, normal vesicular breath sounds are
heard equally in both lungs. No crepitations or rhonchi were detected. Normal vesicular
sound heard over the lung bases and no sacral oedema detected.

Abdominal Examination

On inspection of abdomen, there was no bruising, spider naevi or scratch marks.

There was a trauma scar located right below the umbilicus. The abdomen was symmetrical on
both sides which moves with respiration. There were flank fullness or generalised distention
noted. Umbilicus was centrally located and inverted. Otherwise, there was no stoma,
deformities seen on the abdomen. On superficial palpation, the abdomen was soft without
tenderness in all nine quadrants and no palpable masses were felt during deep palpation of the
abdomen. The liver and spleen were not palpable. Kidneys were not ballotable. Upon
percussion, liver dullness was heard from left 5th intercostal space down to costal margin and
Traube’s space was resonant on percussion which indicates not organomegaly. On percussion
of the nine quadrants, there were tympanic sounds heard all over. Shifting dullness test was
negative. Upon auscultation, bowel sounds were normal, and absence of any bruits included
aortic, renal, and liver bruit.
Central Nervous System
High mental function
Mr T was oriented to time, place, and person.

Cranial nerves (CN) Findings

I - Olfactory  No nose discharge, swelling, blockage or nasal septum
deviation.
 Can identify coffee smell
II – Optic  Normal visual acuity assessed by Snellen chart.
 Normal visual field
 Normal direct and consensual light reflex

III, IV, VI –  No ptosis and squint

Oculomotor, Trochlea,
 Full range of eye movements
Abducens
 No nystagmus

V - Trigeminal  No wasting of the temporalis muscle

 Intact facial sensation
 Jaw jerk reflex and corneal reflex was not done

VII – Facial  Symmetrical face

 Able to raise eyebrows symmetrically
 Close his eyes tight and blow out cheeks
 Able to smile and the angle was symmetrical
VIII – Vestibulocochlear  No hearing issues
 Able to hear whispering sounds
 Rinne and Weber test negative
IX – Glossopharyngeal
X - Vagus
 Able to swallow normally.
 No uvula deviation
XI – Accessory  Able to turn head and shrug shoulder against resistance

XII - Hypoglossal  No tongue wasting or fasciculations

 Able to protrude tongue side to side
 Able to resist against my finger on his cheeks by
pushing his tongue towards his buccal mucosa
Interpretation: All 12 cranial nerves were intact.
 SUMMARY

Mr T, a 26-year-old Indian man who suffered a painful deformity to the distal 3 rd of

his left forearm associated with localised swelling and inability to pronate and supinate his
forearm and all wrist movements after a motor vehicle accident. The pain was exaggerated by
movement and relieved by rest. On inspection, there was swelling of the left forearm and
wrist. Palpation revealed warmth and maximal tenderness over the distal 3 rd of the left
forearm. Range of motion of left wrist and elbow joints could not be examined.
Neurovascular examination could not be carried out due to pain.

PROVISIONAL DIAGNOSIS

1. Open left distal 3rd radio-ulnar fracture.

Supporting Evidence Evidence against

History:
 History of high-impact trauma
 Pain that worsened by movement
 Inability to pronate and supinate
left forearm.
 Deformity of left forearm
 Wound on site of pain
Physical examination:
 Swelling over the distal 3rd of the
left forearm
 Localized rise in temperature over
affected forearm
 Maximal tenderness over distal 3 rd
of the left forearm
 Restricted range of motion of left
forearm
 DIFFERENTIAL DIAGNOSIS

1. Open left distal 3rd radius fracture.

Supporting Evidence Evidence against

History:
 History of high-impact trauma
 Pain that worsened by
movement
 Inability to pronate and supinate
left forearm.
 Deformity of left forearm
 Wound on site of pain
Physical examination:
 Swelling over the distal 3rd of
the left forearm
 Localized rise in temperature
over affected forearm
 Maximal tenderness over distal
3rd of the left forearm
 Restricted range of motion of
left forearm
 2. Open left distal 3rd ulnar fracture

Supporting Evidence Evidence against

History:
 History of high-impact trauma
 Pain that worsened by
movement
 Inability to pronate and supinate
left forearm.
 Deformity of left forearm
 Wound on site of pain
Physical examination:
 Swelling over the distal 3rd of
the left forearm
 Localized rise in temperature
over affected forearm
 Maximal tenderness over distal
3rd of the left forearm
● Restricted range of motion of
left forearm
 RELEVANT INVESTIGATIONS AND INDICATIONS

Investigations Indications
X ray imaging (Chest,  To detect any fracture of bone or dislocation of the elbow or wrist
elbow joint, wrist joint
joint, radius, ulna)  To exclude ribs fracture
 In preparation for surgery
 To detect underlying heart or lung disease
Fasting blood sugar  Assess how well is the patient’s glycemic control
test
HbA1c test  To monitor patients diagnosed with diabetes mellitus.
 To measure the average blood glucose levels over the past 3 months
Renal Profile  To assess for overall kidney health
 To assess hydration status, electrolyte imbalance.
Full blood count  To reflect the patient’s general health
 To rule out presence of inflammation or infection that might
contribute to the source of upper limb pain
 To assess hemoglobin level for anemia (Optimize hemoglobin level
before any surgery and need to be corrected, serve as guidance for
bleeding tendency from platelet count in case of any massive
bleeding during surgical procedure)
Serum electrolyte  To assess the nutritional status
 To assess any bone loss
Coagulation profile  Preoperative assessment
 To detect underlying bleeding or clotting disorders and do prompt
action in case of perioperative bleeding
Preoperative  In preparation for emergency blood transfusion if massive bleeding
investigation for occurs
surgery  To prevent blood group mismatching that may lead to life threatening
hemolytic reaction
 INVESTIGATIONS

1. Full Blood Count

Parameters Results Reference Range

Nucleated red blood cells percentage (%) 0 <1.0
Red Blood Cell count (x10⁶ / μL) 5.94 4.23-5.95
Hemoglobin (g/dL) 13.4 13.5-17.4
Hematocrit (%) 49.1 40.1-50.6
Mean Cell Volume (fL) 82.7 80.6-95.5
Mean Cell Hemoglobin (pg) 27.8 26.9 – 32.3
Mean Corpuscular Hemoglobin Concentration (g/dL) 33.6 31.9 – 35.3
Platelet (K/µL) 231 142-350
Red Cell Distribution Width CV (%) 12.8 12.0-14.8
White Blood Cell Count (K/µL) 8.3 4.1-11.1
Neutrophil Count (K/µL) 6.8 3.9-7.1
Lymphocyte Count (K/µL) 2.5 1.8-4.8
Monocyte Count (K/µL) 0.9 0.4-1.1
Eosinophil Count (K/µL) 0 0 – 0.8
Basophil Count (K/µL) 0 0 – 0.1
% of Neutrophil 75.8 40-80
% of Lymphocyte 20.8 20-40
% of Monocyte 6.2 2-10
% of Eosinophil 0.2 0-6
% of Basophil 0.2 0-1
Interpretation: The results are within normal range

2. Blood grouping and cross-matching

Component Results

Blood group O

Rh group D positive

Interpretation: The patient’s blood group is O positive.

 3. Antibody screening

Component Results

Ab Screen I AHG Negative

Ab Screen II AHG Negative

Ab Screen III AHG Negative

Interpretation: No alloantibodies were detected.

4. Coagulation profile
Parameters Results Reference Range Interpretation
Prothrombin time (sec) 11.9 10-13 Normal
Activated partial thromboplastin time 27.1 25-36 Normal
(sec)
International normalized ratio (INR) 1.09 - Normal
Interpretation: The results are within normal range.

5. Renal profile

Parameters Results Reference Range Interpretation

Urea (mmol/L) 5.4 1.8-7.1 Normal
Sodium (mmol/L) 135 135-145 Normal
Potassium (mmol/L) 4.2 3.4-4.5 Normal
Chloride (mmol/L) 101 <106 Normal
Creatinine (μmol/L) 71 49-90 Normal
Interpretation: The results are within normal range.

6. X-ray of left forearm

- Could not be accessed
PREOPERATIVE DIAGNOSIS PROPOSED FOR SURGERY

Open fracture midshaft left radius and ulna

PLANNED TYPE OF OPERATION

Small DCP left radius and ulna

PLANNED TYPE OF ANAESTHESIA

Local anaesthesia
ANAESTHESIOLOGY
 SUMMARY OF PROGRESS OF THE PATIENT IN THE OPERATING THEATRE

Mr T’s preoperative checklist was verified followed by another round of vital signs
checking by the operating theatre staff nurses at waiting bay. He was also again reviewed by
the anaesthetist in-charge. The breathing system, general anaesthesia machine, ventilators,
airway equipment, pulse oximetry and suction apparatus were checked preoperatively to
prevent any technical errors during surgery. Before entering the operating theatre, he was
given a regional block (supraclavicular block- brachial plexus block). He was placed in a
supine position and the block was ultrasound guided. The needle used was Temena needle
90mm and supraclavicular approach was chosen. There were no complications or difficulties
encountered. Ropivacaine 0.25% was used. He was monitored using ECG, non-invasive
blood pressure, oxygen analyser and pulse oximeter.

Once Mr T was on the operating table, he was placed in supine position. After that,
ECG, pulse oximeter, non- invasive arterial blood pressure and oxygen analyser was applied.
Warming blanket was used Overall, there were no complications during the whole surgery.
Mr T’s vital signs were stable throughout the operation.
 CONDITION ON TRANSFER TO POST- ANAESTHETIC RECOVERY UNIT

Time of transfer ………1705 Hr………………………………….

BP:130/90 mmHg Pulse :82 beats/min RR: - breaths/min
Blood balance IN BALANCE
UP / DOWN ………………ml
Awake / Rousable / Unconscious
In Pain / Shivering.
Airway: oral Pharyngeal reflexes: present
Teeth intact

INSTRUCTIONS TO RECOVERY STAFF

- BP: 128/89
- Pulse: 81 bpm
- RR: -
- Temperature: 36.9 °C
- ECG: Normal
- SpO2 : 98%
- O2: Not given
Give post-operative analgesia: When necessary / immediately / ask Anaesthetist
Vital signs monitoring
Keep SpO2 >95%
Position to be maintained: supine /lateral
Other instruction:
Discharge to · ward / HDU / ICU / other
I Condition on discharge from recovery:
……………………………………………………………
Motor activity: Present / Absent Airway: Cough on command /
clear airway
Conciousness: Aware, Response to stimuli , Protective reflexes
Signature:
Recovery Nurse: Siti Nursyafiqah binti Mohd Yusof……….Anaesthetist …
……………………………
Complication (if any) and Instructions to ward staff:
 - Vital signs monitoring
- Keep SpO2 >95%
- Adequate analgesia
- Anaesthesia pain service team review patient in ward

POST-OPERATIVE SURGICAL DIAGNOSIS

Open fracture of midshaft of left radius and open fracture of distal 3rd of left ulna

PROGRESS OF THE PATIENT IN IMMEDIATE POST-ANAESTHETIC CARE

UNIT (RECOVERY ROOM)

Mr T’s vital signs were monitored, and warming blanket was given to him to keep him warm
in the post operative care unit and to prevent hypothermia. Patient’s vital sign was stable, and
the pain score was 0/10.

STATUS OF THE PATIENT DURING DISCHARGE FROM PACU

Vital signs were stable and continuously monitored. Mr T’s pain score was 0/10 and he was
alert and conscious. He was allowed to be discharged to ward 5A. Instruction was given to
the ward as to give adequate analgesic, monitor vital signs, keep SpO2 >95% and for
anaesthesia pain service team to review patient in ward.
 DISCUSSION

In case of Mr T, he was handled as an elective case as his surgery was planned well in
advanced. According to The National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) which created a classification system to classify the urgency of operations where
Mr T was classified as elective. Therefore, the anaesthesiologist has time to prepare in
advance for the surgery. Mr T was given supraclavicular block. Brachial plexus, subclavian
artery, pleura and first rib need to adequately visualised. The needle is introduced in-plane in
a posterolateral to anteromedial direction and should be continuously visualised to prevent
pleural puncture.
 Besides that, airway assessment is always a compulsory in preoperative evaluation for
safe intubation. For this assessment, we can use the LEMON assessment. Look- we should
look for concerning features such as facial swelling or trauma, dentures, or C-spine
immobilization. Evaluate- we can use the 3-3-3 rule to assess mouth opening and larynx
position. Intubation conditions are favourable if there are at least 3 fingerbreadths of mouth
opening, 3 fingerbreadths of hyomental distance and 2 fingerbreadths of thyrohyoid distance.
In the case of this patient mouth opening was 2.5 fingerbreadths and hyomental distance was
3 fingerbreadths. Mallampati- we can evaluate the oral accessibility via visualization of the
palate and throat with the Mallampati classification. This patient was Mallampati II.
Obstruction/ obesity- we need to check for obstructive conditions or clinical features of
airway obstruction and evaluate body habitus. In this case, the patient was obese. Neck
mobility- We should check for conditions requiring spinal precautions and evaluate range of
motion. In this case, the patient had good range of motion of the neck.

The patient was given ropivacaine which is a long-lasting amide group local
anaesthetic (LA). Amide agents are generally safer than ester agents. Las are drugs that block
sensation of pain in administered region by reversibly blocking sodium channels or nerve
fibres. Ropivacaine is a single enantiomer of bupivacaine. This reduces toxicity potential and
greater separation between sensory and motor blockade. Local anaesthetic toxicity is mainly
caused by intrinsic effects in blocking conduction in all excitable tissues particularly in CNS
and the heart. CNS manifestations includes prodromal symptoms such as tinnitus, metallic
taste, perioral paraesthesia, agitation and/or confusion. Seizures is the most common single
CNS feature and CNS depression also occurs Cardiovascular manifestations (especially with
bupivacaine) results in initial cardiac excitation followed by cardiac depression: Symptoms
include tachycardia, hypertension, tachyarrhythmia (especially with cocaine), bradycardia,
atrioventricular block, asystole, decreased cardiac contractility, hypotension, and cardiogenic
shock. Management includes primary survey and treat acute seizures preferentially with
benzodiazepines. If hemodynamic instability is present lipid emulsion therapy must be
started. Prevention measures include not exceeding the maximum local anaesthetic dose,
using a proper technique for infiltration anaesthesia, and aspirating the syringe prior to each
injection to avoid intravascular injection.
 DISCUSSION ON PATIENT SAFETY AND PROFESSIONALISM
Before taking the history from Mr. T, I approached him and introduced myself as a 4 th year
medical student from UTAR. I asked for permission to take history from him and informed
him that I will be jotting down the information that he tells me. I also assured him that all
information shared will be confidential and will not be misused in any shape or form. After
gaining consent, I moved on to my clerking. I ensured that Mr. T was in a comfortable
position and made sure to not interrupt his chain of conversation and let him finish his
sentences. Before performing physical examination, I explained briefly to him about the
examination that will be done, and I asked him if it is fine with him to be examined without
the curtains on as there were no curtains around his bed. I then sanitised my hands with
alcohol hand rub to prevent cross contamination. I enquired about any pain present before
touching the patient. I also made sure to keep an eye on the patients face to see if he was in
any discomfort. Upon completing my examination, I covered up the patient, thanked the
patient for his cooperation and time. I then sanitised my hand before leaving the patient.

DISCUSSION ON COMMUNICATION AND ETHICS ISSUES

Throughout the clerking session, we were communicating in Tamil as it was the language
both him and I were comfortable in. I avoided using medical jargons and used laymen terms
to avoid any misunderstanding or confusion. This also allows my history to be more accurate.
I also ensured to keep an appropriate eye contact with him and spoke in an audible yet soft
tone to build good rapport and to indicate to him that I am focused and attentive to the
information that he was telling me. If he was unsure about a certain question, I would
rephrase it or explain it in a different way to make it more understandable.
 REFERENCES

Allman, K., Wilson, I., & O'Donnell, A. (Eds.). (2016). Oxford handbook of anaesthesia.
Oxford university press.

Smith, G., Aitkenhead, A., Moppett, I. and Thompson, J. (2013). Smith and Aitkenhead's
textbook of anaesthesia. [New York]: Churchill Livingstone/Elsevier.

The NCEPOD Classification of Intervention (2023). Retrieved from

https://www.ncepod.org.uk/classification.html