summary pt

b23 ikn ward 6A

D37 of admission

ABIDAH BINTI MAHZAN

63 years old, Para 3

Diagnosis:

1. Pelvic mass for investigation

2. Left inguinal hernia

Current issues:

1.HAP complicated with parapneumonic effusion

- CXR on 14/9/2022: Infective lung changes with mild bilateral pleural effusion.
- CRP 36 > 103 > 4.3 > 10.5 > 48.5 (22/9)
- IV Tazosin 4.5g qid since 15/9 - 24/9/22- 10days
- CTA Pulmonary done on 15.9.2022
- No CT evidence of pulmonary embolism
-done left pleural pig tail on 23/9/22
-repeated CXR 26/9/22 imptoving effusion over left side but worsening effusion over right
side
- done right pleural pigtail insertion 30/9/2022

2.Acute pulmonary edema likely secondary (1) and exogenous fluid with underlying
hypoalbuminemia
-noted pt hypoalbuminemia and evidence of third space loss (pleural effusion and bilateral
pitting edema UL/LL)
-Albumin 25, given total 6 doses of IV human albumin
-ECG 24/8: sinus rhythm, no st-t changes
-ECG 8/9: sinus tachycardia
-CXR 23/9/22 repeated worsening of bilateral pleural effusion ( bilateral costophrenic angle
blunted),upperlobe diversion,cardiomegaly

ECHO 21/9/2022
EF 58%
no RMWA
all valves normal

3. Hypoalbuminemia secondary ongoing infection / underlying chronic illness

Done USG Doppler bilateral lower limbs on 7/8/2022:
No ultrasonographic evidence of bilateral lower limb deep venous thrombosis

4. worsening AKI secondary overdiuresis

5. Transminitis
- USG HBS on 23/9/2022:
Features suggestive of acute on chronic acalculous cholecystitis.
Hyperechoic lesion likely focal fatty infiltration.
Ddx: Hemangioma/Ascites
Viral screening Hep B and Hep C 9/9: NR

Currently

saturating under RA
no sob/chest pain or palpittaion
pt able to lie flat

drain chart:

30.9.22: 950/1450 (-500), drain right 900cc left 300cc

1.10.22: 770/950 (-200), drain right 300cc left 600cc
2.10.22 : 800/1050 (-250),drain right 380 cc left 300cc
3/10.22: 980/1100, drain right 40cc left 100cc

IX:
FBC 29/9: wcc 8.3 / Hb 10.6/plt 240
FBC 3/10: wcc 8.4/ Hb 10.3 /plt 281
FBC 4/10: 6.6/ 9.7/263

RP trend from 15/9/22:

ur 13.1 > 14.6 > 14.5 > 16.4 > 13.3 > 15.8 > 16.9 > 16.4 > 17.3 > 17.5 > 18.8 > 17.8 > 19.2 >
21.3 > 22.5 > 21.5
na 135 > 139 > 138 > 139 > 139 > 142 > 140 > 141 > 143 > 141 > 143 > 141 > 142 > 142 >
142 > 144
k 3.8 > 3.1 > 3.1 > 3.9 > 4.5 > 4.1 > 4 > 4.3 > 4.1 > 4 > 3.9 > 3.6 > 3.9 > 3.4 > 3.4 > 3.7
creat 82 > 103 > 127 > 119 > 127 > 161 > 171 > 150 > 159 > 152 > 157 > 121 > 124 > 123 >
119 > 113

coag 29/9: pt 9.4/ inr 0.9/ aptt 32.6

LFT 29/9:
AST 65 > 67 > 65 > 63 > 57 > 64
ALT 54 > 54 > 53 > 54 > 48 > 46
ALP 270 > 270 > 277 > 308 > 266 > 367
Alb 25 > 15 > 21> 24> 23 > 23 > 22 > 18
electrolytes 27/9: ca 1.92/ p04 1.33/mg 0.68
blood C+S 31/8 NG
blood C+S 14/9 NG
blood C&s 25/9/22: Pending
sputum C&S 19/9: NG

urine C&S 31/8: E coli sensitive to augmentin, unasyn,cefoperazone, iv cefuroxime

urine C&S 14/9: mixed growth
urine C&S 18/9: mixed growth
urine C&S 22/9: Not significant growth
urine C&S 29/9: pending

CRP : 3.8 > 4.3 > 10.5 > 48.5 >> 44.2 (25/9/22)
procalcitonin 30/9: pending

peritoneal cytology 2/9: pending

pleural cytology 27/9: negative malignant cells

left pleural fluid

prot 16/ serum prot 5 = ratio 0.29 --> transudative
ldh 407 298 (upper limit 205) = ratio 1.36 ---> exudative
TB gene expert, AFB direct smear pending

24H urine protein 8/8/22: 1.9g/24h

ufeme 22/9: rbc 4+, ketone 2+, prot 3+, nitrite positive, leu 3+

lipid 28/9/22:TC 4.6/ hdl 1.3/ ldl 2.5/ TG 1.7

hba1c 28/9: 5.9

PCT 30/9 0.41

viral screening non reactive

repeat pleural fluid biochem pending

LDH today 294

antibiotics history:

IV cefobid and flagyl 31/8 - 3/9

IV ceftazidime 1g bd 3/9 - 7/9
T.Augmentin 625mg tds 7/9 - 10/9
Tab Azithromycin 500mg od 15/9 - 18/9
IV Tazosin 4.5g qid 15/9 - 20/9
IV Tazocin 2.25g qid (renal dose) 21/9 - 24/9

active medications:

t loratadine 10mg OD
s/c clexane 40mg od
t felodipine ER 10mg BD
T terazosin 2mg od
T Metoprolol 50mg bd
T hematinics II/II od

summary pt
ward 7a ikn

KWAN HOON ENG

65 years old Chinese female

Underlying hypertension, dyslipidaemia
------------------------------------------------
KCO:

1.Right breast carcinoma, ER/PR +ve, Her 2 -ve

- Staging : pT2 N0 (0/3 ) M0 -reexcise : pTx N2M0
- done First surgery Wide local excision of right breast and SLN biopsy done on 12/11/2021
--- Mucinous carcinoma, provisional Grade 1
---pT2(2.5cm ) N0 (0/3) Mx

Post op CT TAP 3/1/22:

Findings : Right axillary lymph nodes 1.5cm , S3 sclerotic bone lesion likely osteoma/ need
to rule
mets , Right breast seroma

-Started on Tamoxifen
- done Re-excision of right axillary clearance in Hospital Kajang 19/1/2022? LN 0/11,
negative
CT simulation scan show persistent right axillary LN
-USG guided biopsy right axillary LN : Mucinous carcinoma , provisional Grade 1
-Underwent 3rd surgery Rt MAC + AC by Dr Ng in Sunway Hospital (19/5/2022):
-HPE : breast ?no residual tumour , axillary LN 4/7 positive invasive mucinous carcinoma,
extracapsular invasion seen ? pTxN2 Mx

Discussed with Dr Patricia , offered chemotherapy FECT regime

Plan:
1) FE(75) C for 3 cycles and docetaxel 75mg /m2 x 3 cycles
2) Recycle every 3 weeks
3) Followed by adjuvant RT to right chest wall and SCF , KIV axilla

Planned for op (RT to right CW, SCF + Axilla 40Gy/15F/3weeks post completion of
chemotherapy)

History of admission post C4 FECT for febrile neutropaenia

- Developed fever with vomiting post chemo
- ANC 0.05, TWC 0.3
- Completed iv cefepime for 1 week
- Given SC GCSF x 2 doses
- Upon discharge, planned to resume C5 chemo with full dose
-C5 FECT full dose given on 23/9/22

*****************************************************************************

Current Issues:

1.Resolved Septic shock secondary to neutropaenic sepsis, with anaemia and

thrombocytopaenia
- On admission TWC 0.6, ANC 0.11
- TWC 0.6 > 0.3 > 4.1 > 7.4 . 10.5
- ANC 0.11 > 0.16 > 3.5 . 6.8 > 10
- Hb 10.5 > 9.2 > 7.5 (Tx PC) > 9.4 > 11
- Plt 126 > 80 . 67 > 51 > 37
- CRP 256.8 > (>320)
- Given iv cefepime 2g stat dose in ACCU
- Then started on iv tazosin 4.5g QID x 1 day (1/10/22)
- Noted patient becoming more lethargic 2/10/2022
- Tachypnoiec under FM 5l/min
- Requiring increment on ivi noad despite fluid challenged
- Subsequently upgraded to iv meropenem 1g BD on 2/10/22
- Blood C&S 30/9/22 and 2/10/22 : SFNG
- Started on double inotropes in ICU (ivi noradrenaline and ivi dobutamine)
- Started on NIV support (BiPAP)

2. Oligouric AKI with metabolic acidosis secondary to (1) - HAGMA

- Urea 8.9 > 12.3 > 16.6 > 20.5 > 22.3 > 25.9
- Creat 178 > 268 > 409 > 439 > 465 > 533
- anuric past 2 days
- given trial fluids
- IV lasix only given 20mg in between transfusion

- anion gap 16.7, albumin corrected anion gap 20.7

- In ACCU, VBG no metabolic acidosis

- ABG on FM 5L/min : pH 7.05, pO2 94, pCO2 56, HCO3 15.5, BE -15
- ABG on BiPAP : pH 7.19, pO2 136, pCO2 40, HCO3 15, BE -12.8
- ABG (2/10/22 Am): 7.202/32.7/132/13.5/-15.2/99
- ABG (2/10/22 Pm): 7.204/29.5/175/13/-16.3/99.3
- ABG (2/10/22 Night): 7.196/29.8/137/12.9/-16.6/98.7
- ABG (3/10/22 Am)7.258/29.4/139/14.7/-13.9/98.9
- latest blood gas ph 7.24,hco3 13.3,lact 1 BE-14
- blood gas today ph 7.34 pc02 32 po2 133 hco3 17.9 lact 1.2
4. Transaminitis due to (1)
- TB 147 > 123 > 93 > 157 (Direct 109)
- ALT 108 > 127 > 117 > 114
- AST 65 > 134 > 122 > 96
- ALP 214 > 129 > 104 > 126
- Alb 34 > 29 > 17 > 24

5. Paroxysmal AF due to (1)

- CK 927 > 452

6. Coagulopathy due to (1)

- INR 1.5 > 1.2

7. Hypomagnesaemia due to GI losses

- 0.67 > 0.73 > 1.08

afebrile
able to wean down to VM today
no desaturation overnight
able to off inotropic support 2/10/2022
pt mildly tachypnoiec under NIV
ABG good oxygenation
still acidotic, anuric
on oral NAHc03 10g BD
pt family not keen for HD support
No more GI losses
feeding to 100mls/3hrly nepro + 100ccH20
'

I/O trend:

30/9 :1183/50 (+1133)

1/10: 2816/210 (+ 2516)
2/10: 3885/83 (+3802cc)
3/10: 1901/215 (+1686cc)
U/O: oliguric(5-10cc/hr)

Blood Ix trend:

30/9/2022:
FBC ; WBC 0.6 PLT 126 HB 10.5 ANC 0.11
RP : NA 136 K 3.3 UREA 8.9 CREAT 178 CL 100
LFT : TB 147 AST 27 ALT 108 ALP 214 TP 62 ALB 35
CA 2.35 MG0.67 PO41.31
CRP : Pending
VBG : ph 7.38 hc03 19.5 lactate NR BE -6
ECG : Sinus rythym
DXT : 11.2

2/10/2022:
Hb 7.5
Plt 67
Wbc 4.1
CRP > 320

Urea 16.6
Na 138
K 4.1
Creat 409

Alp 104/Ast 122/Alt 117

Alb 17
Tbil 93

Cal 2.02
PO 2.08
Mg 0.73

INR 1.5/ PT 16.8/ APTT 47.3

3/10/2022

Hb 11.1, WCC 10.5, Plt 37

RP: 135/3.9/22.3/Creat 465
LFT: TP 50/Alb 24/ALT 114/AST 96/ALP 126/TB 157.1
INR 1.2
Ca corr 2.29
PO4 1.57, Mg: 1.03
CRP: > 320
CK: 927 > 452

4/10/22
fbc twc 27.5 hb 11.5 plt 511
rp 25.9/139/4/533
pt 11.6 inr 1.11 aptt 34.6
lft tp 50 alb 24 alt 78 alp 225 glo 28 tb 119
cca 2.23 p04 1.37 mg 1.53

FBP 2/10 : NCNC anemia secondary to chronic disease

iron 3.2
ferritin pending

culture summary:
Blood C+S 30/9: SFNG
Blood C+S 2/10: SFNG

CRP trend: 256.8 (30/9) ---> 172.6 (4/10)

---------------------------------------------

Active medications;

-IV calcium gluconate 1 ampoule OD 3/7

-T hematinics II/II OD
-IV human albumin 100mls OD 3/7
-IV mgso4 10 mmol OD 3/7
-IV meropenem 1g BD
-IV pantoprazole 40mg OD
-IV parentrovite 1 pair OD 27
-completed s/c neupogen 300mcg OD 3/7 (30/9-2/10)

Antibiotic history:
-IV tazosin 3.37g QID 30-1/10
-IV meropenem 1g BD 2/10 - till date D3 today

Culture history:
Blood C+S 30/9 SFNG
Blood C+S 2/10 SFNG

CXR:Bilateral hazziness

transfusion hx: 2 pint PC 2/10/22