MORTALITY REVIEW

75/Malay/gentleman
Not known medical illness
?Dementia
History of MVA on 24/4/13 sustained closed
fracture of Rt humerus and cerebral
concussion and was treated
conservatively
Patient was bedbound since then
Taking soft diet only



Presented again casualty on 30/4/13
-reduce concious level 1/7 prior to admission
-swelling and redness over rt forearm
-a/w serous discharge
-no fever
-no urti
-no nausea/vomiting
-no uti
-no fitting espisode
Initial assesment
GCS-E4 M5V2
Pupil 2/2 reactive
Bp-109/50
Pr-110
Spo2-100% on FMO2
Cvs-DRNM
Lung-Clear
P/A-soft , nontender
Rt forearm examination
-swollen, redness, warm,blister seen

Blood ix
Wbc-11.2
Hb-9.8
Plt-257
Creat-236 (86)
Urea-34(5.0)
Sodium-151
Potassium-3.8
Chloride-116

ABG
ph-7.434
pco2-32.2
Po2-139
Hco3-21.3
Ufeme
Keton-neg
Blood-2+
Prot-1+
Leu-neg




Management by casualty team
Cxr-clear

Imp-1.Right forearm cellulitis
2.Sepsis secondary to cellulitis
3.right neck humerus fracture
4. Dehydration

Plan
to admit under orthopaedic ward
Iv cloxacillin 500mg qid
Iv c. penicillin 2.4 M qid
To put back slab on rt UL
Strict I/O chart
To refer medical for sepsis
To continue hydration first, for ortho to refer nepro in
ward for AKI
X-ray of Rt humerus and radioulnar
Monitor CVP

1/5/13
GCS improving-E4, V2m6
Bp-121/53
Pr-90 (less tachycardia)
T-37
Spo2-100
i/o-3250/2300 +950
u/o-90 cc perhr
Urea-21
Creat-131
K-3.6
Na-152

Plan
-to insert short line
-hydration according cvp keep cvp 8->12 cm
-ivd 6 pint nS/24hr
-off cloxa and c-pen
-iv tazocin 4.5g bd
-RP/ABG cm




2/5/13
Clinically patient still the same
Plan
-not to put on slab
-elevate hand
-aspirate blister
-cont other mx
4/5/13
GCS-e4 v2 m6
Bp-119/57
Pr-68
Redness reducing
Noted sodium- 161
Blood c+s-NG for 3/7
Plan
-cont iv tazocin 4.5g tds
-cont 6 pint alternat HS and D5
-to refer medical for hypernatraemia

Medical review
5/5/13
GCS-E2V2m4
Bp-98/46
Pr-85
Pt was on HFM 12L/min
Lung-transmitted sound
Wbc-8.15
Hb-8.1
Plt-162

Plan
-for CT-brain
-iv bisolvan 8mg tds
-cont other mx





6/5/13
GCS-E2V2M4
BP-115/50
PR-64
T-37
CT-Brain done-lacunar infarct at lt external capsule
Wbc-15
Hb-7.9
Plt-122
Plan
-to inform regarding ct-brain finding-to start t.aspirin 150mg od and
t.simvastatin 20mg on if no contraindication
DIL/DNR issue to family member-undecided regarding DNR
To d/w again with family member regarding DNR
KIV for intubation if GCS worsening


7/5/13
GCS-E2, V2 M4
BP-144/56
PR-71
SPO2 100 % on HFM2
Plan
Reinsert CVL
Cont iv tazocin 4.5g tds
Pm attended by HO
Noted SPO2 drop 80%
Bp-90/39
Pr-98
GCS-e2v3m5
Lung-transmitted sound
No malaenic stool
No bleeding tendency
Dxt-13
Imp-septic shock secondary to cellulitis
Post suction spo2 pick up to 93-.95%
Post run fast I pint bp-100/39

PLAN
-Cont v/s monitoring
Strict GCS chart
Cont iv tazocin
FBC/RP/ABG/CXR/ECG to review
Kiv inotrope
Kiv intubate

S/B MO
Case noted
Gcs-E2V2M5
BP-80/40
PR-90
ECG-noted
Plan
-start ivi dopamine
-trace ix
-cxr
Wbc-15.6
Hb-7.8
Plt-142
Urea-11.1
Creat-70
Sodium-156
K-3.4
Chloride-124
ABG-
8/5/13
Gcs-E3V2M5
BP-110/56
PR-110-on iv noadrenaline and iv dopamine
p/a-soft
Lung-transmitted sound

Plan
Cont iv tazocin D6
Cont other mx
Pm
Spo2 drop 56%
Bp drop-60/30

s/b MO
DIL and DNR issue

Plan
-cont HFM2 15L/MIN
-cont inotrope-not for escalation
-cont antibiotic
-cont ivd

9/5/13
GCS-7/15
Tachypnea
Bp-111/46
Pr-140
Spo2-95%
T-37
i/o-1241/945-+296

Plan
Cont iv tazocin
Cont HFM2
Cont inotrope support





10/5/13

GCS-E2V2M3
BP-109/78
PR-152
SPO2-99
Lung-transmitted sound
p/a-soft, not distended

Plan
-cont current mx

11/5/13
GCS-E2V2M2
BP-116/49
PR-127
P/A-soft, not distended

Plan
cont current mx
12/5/13
GCS-E1M1V1
BP-101/33
PR-112
SPO2-99
P/A-soft, not distended

Plan
-cont current mx
13/5/13
2.40 am
Pt asystole

Was refer to medical in casualty for AKI
-to continue hydration and to refer nephro