SECTION

SUMMARY (House officer)

Biodata

Name
Age
Sex
AS
DOA
DOD

:
:
:
:
:
:

Othman Bin Itam

76Y,
Male
AS00116181
29/4/15
10/5/15

History

Was brought in by family members as patient complaining of abdominal distension

+ reduced oral intake
+ worsened lower limbs swelling
no fever at home, no nausea no vomiting
no SOB, no cough
-further history from PAP (wife)
patient is unwell since 3 weeks prior to admission as he developed swelling over the
perianal region
Since then became very unwilling to ambulate due to pain
Was admitted to Hospital Kangar for 5 days then opted for AOR discharge, no
operation was done at that time
Discharged with antibiotics at home (unsure medication name)
+ LOA and LOW since 1 month
previously had diarrhea for past 1 month

Underlying
:

Examinati
on

1) DM
2) HPT
3) Chronic AF
- previously under Hospital Kangar f/up
- stopped T warfarin last year
Examination in ED
o/e: alert, conscious, not tachypneic under RA
BP: 110/78
PR: 173 (AF)
T: 37C
SpO2: 98%
PA: distended but soft, non tender no guarding
Inguinal LN palpable on the left, no cervical lymphadenopathy no supraclavicular node
DRE: perianal wound 0.5x0.5 cm at 7 oclock position, 1cm from anal verge
noted pus discharge from the wound
constricting mass in anus, 2cm from anal verge, able to pass through index finger with
contact bleeding
Blood ix
TWC: 15.29,hb: 9.2, PLT: 229
Creat: 82 Urea:9.0 Na: 129, K: 4.1
CEA : 12.2
Started IV unasyn 1.5g TDS on the same day

ISSUE
(Medical
officer)

IMP:1) Rectal Ca with nodal metastasis

2)Left perianal and thigh abscess
Progression

While admitted in 4A pt and PAP initially were undecided for op

Explaination given to patient and PAP regarding risks of operation and post op
complications clearly in ward, and subsequently agreed for op.
Underwent on 3/5/15
1. incision and drainage + wound debridement over left perianal and thigh abscess
2. trephine transverse loop colostomy
Dx:
1.Rectal CA with anal canal involvement
2.Left perianal and thigh abscess
Findings:
1.Pus drained out about 300cc, muscle healthy
2.pus and slough send for c+s
3.punch biopsy of rectal tumour taken
4.clear ascitic fluid in peritoneum
5.transverse colon not dilated
6.distal washout - minimal stools
Post op patient was transferred to ICU for further close monitoring as intraoperatively
pt developed hypotension and was transfused 2 pint packed cells intra-op
Day 2 (5/5/15) post op noted, Hb dropped to 7.0 and INR prolonged 1.27 with fresh
melena noted in the stoma, transfused 2 pints PC and proceeded with bed side OGDS
on 6/5/2014, findings:
-esophagus normal
-antrum and body normal
-pylorus not deformed
-visible vessel, D3 forrest IIa, clipped x 2, injected IV adrenaline 2-3cc
-Large forrest III at D2
Dx: Forrest 2a ulcer at D3
Noted sputum c&s 3/5/15 Klebsiella Pneumonia &pseudomona Aeruginosa
Sensitive to Tazocin
Antibiotic change to IV tazosin 4.5g QID
-covered for HAP
Day 4 (7/5/15) post op patient was successfully extubated to VMO2 and T/O to general
ward 3C, there was started on clear fluids as no more melena noted in stoma/per
rectum examination greenish stool in stoma and able to wean down oxygen to
NPO2 3L/min.
Day 5 (8/5/15) post op pt developed another episodes of melena in the evening, with
distal part of stoma full with melenic stool. IV tranxenamic acid and IV vitamin K
started. Hb dropped from 9.3 to 7.6. Tranfused 1 pint packed cell, feeding was with
held, and close monitoring done
Day 6 post (9/5/15) op patient was planned to repeat OGDS as still passing melenic
stool in the stoma, with Hb 7.2, PLT: 54, INR: 1.6.
OGDS findings:
-stomach normal , no blood clots

-Duodenum
-D1- Normal

-D1,D2 healed ulcer

-D3 clip intact , no active bleeding
Imp: resolveb UGIB
Proceed with colonoscopy on the same day
Findings :
Melenic stool in tranverse colon
Stool ++
Unable to proceed further
1 set DIVC regime was transfused on the same day together with 2 pints packed cell ,
IV lasix 20mg given stat in between packed cell transfusion.
Later BP reading started to drop persistently to 90-96/58-68 in the evening hence
started on IVI noradrenaline infusion 10mcg/hr on 9/5/2015 and transfused another 2
unit of platelets at that time.
On 10/5/15, upon attending patient for blood taking at 3.55 am noted patient suddenly
desaturated to 79% on NPO2 3L/min, with recordable pulse 30/min,no spontaneous
breathing noted, and BP was unrecordable. Subsequently changed to FMO2 5L/min
then CPR commenced for 10 minutes as patient further deteriorated. IV atropine given
1 unit with on going IVI adrenaline 8cc/hour, manual bagging also done.
Case informed and D/W Dr Fikri (MO on call), he did informed that DNR was issued
earlier last night to patient's wife and family members and all of them are not keen for
any active resuscitation. CPR stopped at 4.10 am.
Dr Fikri reassed back patient later after 30 minutes, noted BP was unrecordable, no
carotid pulse palpable no spontaneous breathing seen, pupils bilaterally dilated and
not responded to light , no gag reflex present, ECG monitoring showed no cardiac
activity, auscultation no breathing and heart sound heard.
Pronounced dead at 4.40H with COD: Sepsis secondary to nosocomial pneumonia
with Upper Gastrointestinal Bleeding.