sample of mobidity

1. MORBIDITY REVIEW
BY DR ARASAKARTHIYAYINI
MADAM M
ADMITTED SINCE 14/8/23
DISCHARGED WELL ON 4/9/23

2. 53 years old Malay lady
Underlying
• DM with nephrotic range proteinuria
• Hypertension
• Dyslipidemia
• CKD stage 5 secondary to DM nephropathy
• -Baseline creatinine Nov 2022 -296
• HF pEF
• Echo -61%no cherry top appearance
• Concentric hypertrophy
• Blood protein electrophoresis : suggestive of nephrotic syndrome ,no monoclonal
paraprotein
• LE tractional retinal detachment
• Under opthal

3. • Medication :
• Tab Atorvastatin 40mg ON
• Tab Felodipine 10mg BD
• Tab Spironolactone 25mg BD
• Tab Cardipirin 100 mg OD
• Tab Gliclazide MR 30 mg OD
• Tab Bisoprolol 2.5 mg OD
• Tab Frusemide 80 mg BD

4. • Patient came to TCA on 14/8/23 to nephrology clinic
• Upon review @11.53 am
• No vomiting
• No complaints
• Eating less
• Noted blood ix
• Urea 47.5 cr 882 k 6
• 24 H urine protein 4940
• PH 7.26 Hco3 16.8
• Corrected calcium 1.78
• Alb 32
• Hb 6.9 wbc 6.7 PLT 321
• Pt was counselled regarding RRT initiation ,blood results deranged and need urgent catheter
insertion for dialysis .Pt understood

5. • Plan :
• Admit ward ,preferable 7 b
• Insert FVC and urgent HD with 2 pints blood transfusion
• IV calcium gluconate 1 amp over 30 min
• To meet family member to talk about RRT modality and
PD assessment

6. • Pt was admitted to ward 8b on 14/8/23 at 9.56 pm
• Clerking done by HO at 1am
• Upon admission to 8b
• Afebrile
• No sob
• No headache /dizziness
• Tolerating orally
• BP 187/85
• PR 60
• T 37
• Spo2 -96% under RA
• PLAN : continue nephro plan
• Tab Felodipine 10mg stat and BD
• Continue other medication
• CXR and ECG cm
• Case not seen by any MO or specialist in ward

7. • Nephrology review on 15/8/23
• For FVC insertion today and for HD 2 H Transfuse 2 pints
PC during HD
• UF 1 L +blood product
• To meet family member for RRT
• T/O to 7b if bed available
• Off spironolactone

8. • FVC attempted at 1.50 pm
• Right FVC attempted x1,single attempt blood flow noted not pulsatile .
• Upon insertion guidewire noted small hematoma ,guidewire removed and
compression done
• Left FVC attempted by 2 nd MO x2 failed ,subsequently taken over by 3 rd MO .Left
FVC inserted with
• single attempt
• Good inflow and outflow
• Planned for HD with heparin free
• HD done on 16/8/23 -uneventful

9. • 17/8/23
• Upon morning review pt c/o pain over right leg
• Issues : Iatrogenic right superficial femoral artery
pseudoaneurysm
• U/S doppler right leg done : An anechoic structure seen in
right proximal anterior thight measuring
• 1.8 x1.8x2.6cm .This structure shows turbulent flow with a
ying yang sign seen.It is a arising from the
• right superficial femoral artery with narrow neck seen .No
perivascular hematoma seen

10. • CTA right lower limb 18/8/23
• Saccular pseudoaneurysm measuring 1.8cmx1.9
cmx2.4cm seen arising from the proximal part of
• right superficial femoral artery .Slightly compressing the
right superficial femoral artery with
• narrowest measuring 0.3cm
• U/S guided compression done for 1 hour:no significant
changes noted.Pseudoaneurysm measuring
• 1.6x1.8cm with doppler colour intake

11. • CTA right lower limb 18/8/23
• Saccular pseudoaneurysm measuring 1.8cmx1.9 cmx2.4cm
seen arising from the proximal part of
• right superficial femoral artery .Slightly compressing the right
superficial femoral artery with
• narrowest measuring 0.3cm
• U/S guided compression done for 1 hour:no significant changes
noted.Pseudoaneurysm measuring
• 1.6x1.8cm with doppler colour intake
• Case referred to vascular KL
• Case transferred to HKL for stenting
• Pt was discharged well on 4/9/2023

15. Take home message
• Need to use U/S probe for FVC insertion
• Minimum attempt x3 per person ,need to call help if needed
• Compression need to be done atleast 10 minutes
• Need to passover case to ward Mo upon admission -for active urgent plans
• If no beds available -can push to ED and for urgent FVC insertion and make sure pt
done HD if bed is not available yet
• Those admit need to make sure plans are carried out
• Those new to department -need to ask assitant from ward MO for procedures if not
confident to do
• cases admitted to ward need to clerk and plan carry out as soon as possible