Mr Haizrul Izwan bin Khalid, 45 y/o. male, malay transfer in from ED at 2225H.
Brought in to ICU via
wheelchair accompanied by SRN Hanida. Had complaint of headache, left side neck pain and woke
up with jaw claudication today. Patient diagnosed as ACS, Unstable angina, TRO NSTEMI. Had
medical history of DM, HPT. Patient have own medications at home. PIVC inserted at left cephalic
size 18G.
Allergy: Not known
General condition on arrival alert and conscious. Able to walk. Breathing spontaneously under room
air. Appear pinkish. All peripheries warm to touch and capillary refill less than 2seconds. PIVC at left
cephalic size 18G.
REMARKS:
· ECHO CM
· DXT QID
· IX IN WARD
-SERIAL ECG
-RPT CARDIAC MARKERS CM
· TRACE PENDING IX
· AIM SPO2 > 95%
· STRICT I/O CHARTING
· TO R/V PT'S MEDS and CONT MEDS AS CHART
· S/L GTN 1/1 STAT & PRN
· S/C ARIXSTRA 2.5MG STAT
· ADMIT ICU
CNS: GCS 15/15 (E: 4, V: 5, M: 6). Able to move both upper and lower limbs with normal power.
Muscle score of 5/5. Both pupils 3mm equal and reactive to light.
CVS: Appear pinkish. All peripheries warm to touch. Capillary refill less than 3seconds. Pulse felt.
Slight discomfort at chest area.
RESP: Breathing spontaneously under room air with SPO2 >97% and RR ranging 15-25 breaths per
minute. No SOB noted.
GIT: Abdomen soft to palpate. Allow orally as tolerated with DD, LSD, and LFD.
GUT: Voided spontaneously at toilet.
SKIN: Skin moist and intact. No skin breakdown seen at bony prominence area
LINES: PIVC intact at left cephalic size 18G. VIP score 0. No phlebitis seen.
INFUFIONS: NIL
3/10/2022@2245H
ECG done. DXT checked. 13.5mmol/L. Patient performed Isya’ prayer at bedside.
3/10/2022@2300H
Patient taken dinner. Medications given as prescribed.
3/10/2022@2315H
Try to call Prof Oteh but failed. Inform latest patient condition and blood results via whatsapp.
Verbal order by Prof Oteh to:
- Ask MO to fill up add on procedure for angio
- If BP high give GTN
- If normal give Morphine 2.5mg and Maxolon 10mg
3/10/2022@2330H
Assess patient condition. No chest pain but slightly chest discomfort. Offer painkiller as order by Prof
Oteh but patient refuse for now. He will inform if he need it later.
4/10/2022@0000H
Vital sign checked and recorded as per ICU chart.
4/10/2022@0030H
Seen by Prof Oteh. Assess patient condition. Explained to patient regarding angiogram procedure.
Consent obtained. STAT medication given as prescribed. Plan Prof Oteh to:
· Cont DAPT, Fondaparinux
· dxt tds KIV insulin SC if dxt consistently >8mmol/l
· Emergency cathlab activation for Primary PCI - consent obtained
· For daily ECG/trop I
· Echo cm
4/10/2022@0115H
Send patient to Cathlab via bed accompanied by SRN Shafikah and SRN Firdaus. Passed over case to
SRN Muslina.
4/10/2022@0245H
Patient returned from Cathlab via bed accompanied by SRN Muslina. Patient undergone coronary
angioplasty DEB x2 at RCA via Right radial. No oozing or bleeding seen. Covered with nichiban.
Nichiban to remove at 0645H.
Post Angioplasty plan:
· Keep in ICU
· ECG stat
· DAPT with ticagrelor/cardiprin
· ECG/RP/trop I/FSL/FBS cm
· Routine radial obs
ECG done.
4/10/2022@0310H
Seen by Prof Oteh. Review medication chart and latest ECG. Plan Prof Oteh to:
· Cont meds
· add metoprolol
· resume his micardis 40mg
· other plans as per PCI report and prev entry
4/10/2022@0400H
STAT medication given as prescribed. Vital sign checked and recorded as per ICU chart.
4/10/2022@0600H
ECG done. Blood sample taken and sent to lab. DXT checked. 15.6mmol/L. Remind patient to
perform Subuh prayer.
4/10/2022@0630H
Reassessment done. GCS 15/15. Able to move both upper and lower limbs freely. All peripheries
warm to touch. Pulse felt. Capillary refill less than 2 seconds. Breathing spontaneously under room
air with SPO2 >97%. Allow orally as tolerated with DD, LSD, and LFD. Voided spontaneously via
urinal. Good urine output. Skin moist and intact. Puncture site at right radial covered with nichiban.
No bleeding or oozing seen. Nichiban to remove at 0645H. PIVC at Left Cephalic size 20G intact.
Dressing applied and intact. VIP score 0.
4/10/2022@0645H
Nichiban removed. Still bleeding. No hematoma seen. Pressure dressing applied at puncture site.
REMARKS:
· RP, Trop I, FSL, FBS to trace
· ECG to review
· dxt tds KIV insulin SC if dxt consistently >8mmol/l
· For daily ECG/trop I
· Echo cm
4/10/2022@0700H
Pass over report to SRN Haslina for continuity of care
