The document summarizes 9 patient handover cases from the ETD on 20-21 May 2023. Case 1 involves a 42-year old female with a left thigh hematoma from over-warfarinization. Case 2 is a 27-year old female with a closed left wrist perilunate dislocation following a cycling accident. Case 3 is a 57-year old male with necrotizing soft tissue infection of the left leg and diabetic ketoacidosis who went into cardiac arrest.

1. ETD HANDOVER
20/5/23 - 21/5/23
Surgeon: Mr Raeross
Registra: Dr Jasper
OT call: Dr Sophia
Ward call: Dr Tey
ETD call: Dr Nora

2. Case 1
FMW B2
Rasidah Binti Mat
810221135772
42 years old, female
U/L HPT, DPL, HD 1 3 5, double mechanical valve replacement
H/O RTA on 5/4/2023, admitted on 15/4/23-5/5/23 for left thigh hematoma
Prev on T warfarin 4.5 g OD
Ht 160 cm Wt 55 kg BMI 20.2

3. HOPI
Referred TRO compartment syndrome
Patient complained of left thigh swelling and pain for 3 days
No fever
No LOC/LOA
Unable to ambulate due to pain

4. On examination
GCS full
BP 145/93
HR 86
SpO2 99% under RA
T 36.3

5. On examination
Left thigh
Lateral thigh swelling
15 cm x 10 cm, not warm, non erythematous, soft
ROM hip & knee limited due to pain
ROM ankle full
Thigh diameter: Right 38.5 cm, left 45 cm

9. Xrays (15/5/2023)

12. Blood ix

13. Impression: Left thigh hematoma secondary to
overwarfarinization
Plan:
1. To observe swelling, KIV for USG id increasing in size
2. Withhold warfarin
3. Peri ortho to review

14. Medical plan:
1. For daily INR + FBC
2. To request ultrasound thigh
3. Refer nephro for HD
4. Monitor swelling
5. Watch out for compartment syndrome
6. Inform if pain worsening
7. Withhold warfarin for now
8. To start s/c clexane if INR <1.5
9. To transfuse 1 pint packed cell during HD today
10.HPC QID for 1 day

15. Case 2
FOW B1A
Tan Seok Cheng
951205135368
27 years old, female
NKMI, NKDA
Left hand dominant
164 cm 60 kg BMI 22.3 kg

16. HOPI
Alleged self RTA today (20/5/2023) at 8 am
Helmeted cyclist
Claimed to lose balance then fell on her left side before rolling forward
Fell face first and then hit the left wrist and right knee
Post trauma, transient LOC
Still able to remember mechanism of trauma
Able to ambulate
Post trauma, sustained pain over face and left wrist

17. On examination
GCS 15/15, speaking in full sentences
Equal bilateral air entry, chest rise equal
BP 117/88
HR 107
T 36.2
SpO2 99% under RA

18. On examination
ROM neck full
No cervical tenderness
No midline tenderness, no step deformity
No bruises over back
Able to move all limbs

19. On examination
Right upper limb
ROM shoulder, elbow, wrist full
No bony tenderness
Superficial abrasion wound over volar hand

20. On examination
Right lower limb
Laceration wound over knee - done t&s
ROM hip, knee, ankle full

21. On examination
Left upper limb
ROM shoulder & elbow full
Tenderness over wrist

22. Chest xray: clear

23. Cervical xray: no fractures seen

24. Pelvis xray: no fractures seen

25. Left humerus xray: no fractures seen

26. Left radius and ulna xray: no fractures seen

28. Left hand xray: Perilunate
translate dislocation

30. Post CMR x 1

31. Blood ix
WBC 9.4
HGB 11.8
Plat 347
PT 12.6
PTT 29.1
INR 1.12
Na 132
K 3.8
Cl 98
Urea 3.6
Creat 59
CT brain clear

32. Impression: Closed left transcaphoid perilunate dislocation
Plan:
1. For CT scan of left wrist
2. Keep volar slab
3. Monitor left NVS
4. IV tramal 50 mg TDS, T PCM 1 g TDS
5. Refer hand cm
6. Check socso status

33. Case 3
ICU extension Bed 14
Razak @ Abdul Rzak Bin Saleh
660514135249
57 years old, male
U/L DM, DLP under MIPD follow up (Did not inject insulin for more than 2 days)
H/O Ray’s amputation 3/4th toe left in 2011
ADL independent
Ht 165 cm Wt 80 kg BMI 29.3

34. HOPI
Left foot big toe wound for 2 months
Unwell for 2 days
Self dressing at home
Pus discharge for 2 days
POI for 2 days
Abdominal pain for 1 day
Associated with lower limb swelling
Denies fever / SOB / chest pain / cough / vomiting
Found unconscious this morning (20/5/2023) by family members and brought to ETD

35. On examination
GCS upon arrival E1V2M2, pupils 35/25
BP 59/27
HR 111
T 36.6
SpO2 99% under HFM
Patient asystole, undergone CPR x2

36. On examination
Give 4 pint NS bolus, IV tazosin, NaHCO3
Currently intubated and sedated
BP 123 / 53 (under norad)
HR 121
SpO2 100% under FiO2 0.5

37. On examination
Left lower limb
6 cm x 3 cm wound over anterolateral aspect of big toe
Base mildly sloughy
1 cm x 1cm wound over base of first phalanx
Pus discharge upon milking
Crepitus felt over distal calf

41. Chest xray: fairly clear

42. Left ankle xray: ++ gas shadow over posterior ankle

43. Left foot xray: OM changes over proximal / distal phalanx
of first toe and MTB, no gas shadow

44. Blood ix
TWC 40.8
HGB 8.2
PLT 901

47. Impression:
1)Severe necrotizing soft tissue
infection of left LL in septic shock
2) DKA with severe metabolic
acidosis secondary to miss insulin
and 1
3) Post CPR X2
Plan
- Peri ortho to review
- IV tazosin 4.5 g QID
- IV clindamycin 400 g TDS
- Daily dressing over left foot NS jelonet
- To post for left BKA kiv AKA under red
code
- High risk consent

49. Case 4
FOW B25A
Chia Choon May
430401135230
80 years old, female
u/l chronic venous insufficiency under SOPD (no meds, on yearly follow-up)
ADL independent (no walking aid)
Ht 160 cm Wt 60 kg BMI 23.4

50. HOPI
Alleged fall 10 am today (20/5/23) while walking due to slippery floor
Pre fall, no dizziness, no SOB, no LOC, no headache
Post fall, sustained pain over right hip and unable to ambulate
No head trauma
No ENT bleed
No other injury

51. On examination
GCS full
BP 134/74
HR 92
T 36.2
SpO2 99% under RA

52. On examination
Right lower limb
No bruises, swelling over right thigh
Externally rotated
DPA, PTA strong (similar to left side
Sensation intact
No foot drop

53. Chest xray: No cardiomegaly

54. Pelvic xray: Right IT fracture

56. Blood ix
TWC 6.93
HGB 10.5
PLT 141
Na 128
K 3.9
Cl 108
Urea 6.1
Creat 93
TB 9/ DB 4
TP 60/ Alb 32
ALT 8
ALP 76
Corr Ca 2.23
PO4 1.09
Mg 0.76

57. Impression: Closed right IT fracture
Plan:
1. Refer APS / orthogeri
2. For skin traction 3 kg
3. NVS charting of right lower limb
4. Admit ortho
5. ECHO inpatient
6. FLP / FBS cm
7. HPC QID in ward
8. IVD 2L / NS in ward
9. Start s/c clexane 20 mg OD, T PCM 1g TDS, T Tramal 50 mg TDS
10.Short PFN later

58. Case 5
FOW B3A
Sofiahti Binti Yasir
660207615058
57 years old, female
U/l HTN, DM, right eye cataract
H/o Right Ray’s amputation of 3rd and 4th toe > 5 years ago
HT 160 cm Wt 55 kg BMI 21.5

59. HOPI
p/w right big toe swelling for 2 weeks
Pus discharge for 1 week
On and off fever
Denies h/o trauma, insect bite, or fall
H/o visiting GP 15/5/23, discharged with azithromycin 500 g OD (D6)

60. On examination
GCS full
BP 158/94
HR 104
SpO2 100% under RA
T 36.6
HPC 16

61. On examination
Right foot (dorsal)
CRT < 2s
Wound well healed
3cm x 3cm swelling over big toe, fluctuant,
associated with redness

63. On examination
Right foot (plantar)
1 cm x 1 cm wound
Pus discharge upon milking
Non tender beyond MTPJ
Midfoot, forefoot, hindfoot non tender

65. ABSI
Right food 1.14
Left foot 1.10
Monofilament:
Right 8/10
Left 7/10

66. Chest xray: no cardiomegaly, lungs field
clear

67. Right foot xray:
OM changes over distal
phalanx of first toe
No gas shadow seen

68. Blood ix
FBC
HGB 12.1
TWC 11.7
PLT 439
VBG
pH 7.35
HCO3 30.2
Ketone: negative
Na 133
K 3.0
Cl 91
Urea 4.9
Creat 89
CRP 24.2

69. Impression: 1) Right big toe DFU 2) Uncontrolled DM
Plan:
1. Admit orhto ward
2. IV unasyn 1.5 g TDS, T PCM 1g TDS, T Tramal 50 mg TDS
3. Daily dressing
4. Keep NPO with IVD 2 L NS
5. HPC QID in ward, if HPC > 12, start ISS scale 3
6. Refer medical for uncontrolled DM
7. HbA1c, FLP, FBS cm
8. To post for wound debridement and right big toe disarticulation at MTPJ
9. Indent old medications

70. Case 6
MOW B17A
Othman Bin Sa’et
530217135247
70 years old gentleman
Pensioner (ex maybank officer). Currently doing farming at
Ht 170, Wt 65kg, BMI 22.49
Underlying DM and hypertension (since more then 10 years ago)
Non smoker and non alcohol drinker

71. HOPI
Presented with left leg selling since 4 days ago
Associated with itchiness and pus discharge
Otherwise no fever, good oral intake, no LOW/ LOA
No PTB contact

72. On examination
Alert, E4V5M6, not septic looking
BP 157/72
HR 108
T 37
SPO2 1OO under RA
HPC 12.7
Lungs: clear

73. Left lower limb
- Swollen from foot up to knee
- + redness
- Fluctuant over midshin
- + punctum with pus discharge
- ROM knee and ankle full

78. Blood Investigation
Hb 9.9
TWC 13.7
Plt 673
PT 12.6
PTT 30.4
INR 1.12
TB 9/ DB 6
TP 72
Alb 31
ALT 22
ALP 310
AST 12
Na 121
K 3.8
Cl 90
Urea 2.8
Creat 63

79. Impression
Left leg abscess
Plan
- Admit ortho
- To post case for Incision and drainage of left leg
- IV Unasyn 1.5g TDS
- T Paracetamol 1g TDS
- IV Tramal 50mg TDS
- Indent old meds
- NPO with IVD 2L/day NS
- HPC QID
- If HPC >12 during NPO, to start ISS scale 2
- ECG stat

80. Case 7
FOW B7A
Bedut Anak Entak
581112135304
64 years old lady, Farmer
Ht 155cm, Wt 45kg, BMI
NKMI, NKDA

81. HOPI
Alleged dog bite over left leg at 6pm 20/5/2023
- Stray dog (unprovoked)
- Post trauma sustained pain and bleeding over left leg
- Still able to ambulate
- No other injury seen

82. On examination
Alert, E4V5M6, not septic looking
BP 151/80
HR 77
T 36.5
SPO2 100 under RA

83. - Around 1x1 cm wound over left
lateral leg
- Oozing blood
- No pus discharge
- No muscle cut

87. Blood investigation
Hb 8.9 (Hct 27.9, MCV 91, MCH 29.1)
TWC 8.6
Plt 229

88. Impression
Left leg wound secondary to dog bite category 3
1. For human RIG and rabbies vaccine stat
2. Cont. ID plan - Rabbies vaccine Day 3
(24/5/23) and Day 7 (28/5/23)
3. Keep NPO at 2am with IVD 2L/day NS
4. To post for WD of left leg cm
5. IV Augmentin 1.2g TDS, T. Pcm 1g TDS
6. Daily dressing till OT call
7. HPC stat then QID

89. Case 8
FOW B11A
Abby Anak Stephen
811205135128
41 years old lady
Ht 165cm, Wt 100kg, BMI 36.7
Underlying: morbid obesity
Right hand dominant

90. HOPI
Alleged fall at 5pm 20/5/2023 due to slippery floor
Fall on outstretched hand over right side
Post trauma sustained pain and deformity over right elbow
No head trauma/ ENT bleed/ retrograde amnesia
Post trauma able to ambulate

91. On examination
Alert, E4V5M6, not tachypneic
BP 160/96
HR 79
T 36.7
SPO2 99 under RA
FBS 5.9

92. Swollen on right elbow
ROM limited due to pain
Sensation over median/ Ulna/ Radial site intact
Able to oppose and abduct thumb
No wrist drop/ finger drop
Able to abduct fingers
Radial/ ulna pulses palpable (equal to left side)

97. Post CMR x1

98. Post CMR x2

99. Blood investigation
Hb 12
TWC 11
Plt 392
Na 138
K 3.8
Cl 107
Urea 3.1
Creat 50

100. Impression
Posterolateral right elbow dislocation
with radial head fracture
Plan
- Admit ortho
- For CT right elbow (for bone configuration)
- ECG stat
- FBS/ FLP/ Hba1c cm
- HPC QID in ward
- Monitor neurovascular charting over right lower limb
- C Tramal 50mg TDS
- T Paracetamol 1g TDS
- Keep above elbow cast
- KIV refer hand

101. Case 9
FOW 27A
Hadiah Binti Su’Ut @ Su’Ud
390930135232
83 years old lady
Ht 155cm, Wt 60kg, BMI 24.9
Underlying dyslipidemia on atorvastatin 20mg OD
ADL semi dependent (Using walking stick)

102. HOPI
Alleged fall yesterday evening due to slippery floor in bathroom
Post trauma sustained pain over left hip, unable to weight bear
Otherwise no head injury/ ENT bleed/ retrograde amnesia

103. On examination
Alert, E4V5M6, not tachypneic
BP 121/62
HR 88
T 37.1
SPO2 98 under RA
HPC 8.3
Left lower limb
- Externally rotated
- No foot drop
- DPA/ PTA palpable
- Sensation intact
- No bruises seen
Lungs: fairly clear

108. Blood investigation
Hb 11.9
TWC 8.7
Plt 208
PT 11.7
PTT 28.3
INR 1.04
Na 135
K 4.2
Cl 101
Urea 4.4
Creat 99

109. Impression
Closed fracture of left
intertrochanteric femur
Plan
- Admit Ortho
- For skin traction
- Start S/C Clexane 20mg OD
- T Paracetamol 1g TDS
- C Tramal 50mg TDS
- Refer APS
- Neurovascular charting of left lower limb
- HPC QID
- Indent old meds
- KIV allow discharge after 1-2 weeks traction
- Refer physio in ward

110. Case 10
POW B17B
Jonathan Anak Rudin
751212135503
48 years old gentleman
Right hand dominant
Ht 165cm, Wt 45kg, BMI 16.52
Underlying hypertension

111. HOPI
Alleged RTA at 5pm 20/5/2023 (referred from H. Lundu)
Not helmeted MB VS Car
Fall over right side
Otherwise no head trauma/ ENT bleed/ retrograde amnesia
Able to ambulate

112. On examination
Alert, E4V5M6, not tachypneic
BP 147/101
HR 110
T 36.7
SPO2 99 under RA

113. Right hand
1) Superficial laceration wound over ring
finger base MTPJ (2x1 cm)
- Able to extend DIPJ/ PIPJ
- Sensation intact (radial and ulna side)
- CRT <2s
1) Deep laceration wound over little finger
base of MTPJ (2X1 cm)
- Sensation over radial site reduced
- Still able to extend DIPJ/ PIPJ
- CRT <2s

117. Blood investigation
Hb 13.1
TWC 15.6
Plt 332

118. Impression
Open fracture of proximal phalanx of right
little finger
Plan
- Admit ortho
- NPO with IVD 2L/day all NS
- For wound debridement and K-wire of right
little finger
- IV Cefuroxime 750mg TDS
- T Paracetamol 1g TDS
- IV Tramal 50mg TDS
- ECG stat
- Daily dressing until OT call

119. Case 11
Red Zone 1
Mr 033656ETD 23
age around 20+
Ht 160cm, Wt 55kg, BMI 21.4
Homeless (No family members/ witnesses around)

120. HOPI
Found unconscious in the middle of the road at 10.30 pm 20/5/2023 by
bystander
No witness
Unknown mechanism of injury
Post trauma
- Reduces responsiveness
- Multiple abrasion wound

121. On examination
Unable to assess patient as GCS is drop
(E3V2M5)
BP 138/81
HR 80
SPO2 97 under RA
T 36.8
A: airway pattern, no girgle sound
B: equal air entry
C: bp not supported, no oozing of wound seen
D:
+ ENT bleed/ multiple laceration wound over
scalp, left hip/ lumbar, left elbow.
+ Deformity over left elbow. Clinically non
tender, non mobile

125. CTB reviewed by neurosurgery
- Thin right FTP SDA (ctb 2 hour) +
Maxillary sinus fracture
(Pending formal report)

126. Blood investigation
Hb 13.9
TWC 28.3
Plt 149
Urine Toxic negative
VBG under RA
pH 7.36
HCO3 22
BE -3.2
Lact 2.0

127. Impression
1) Traumatic ICB with moderate TBI (under
neurosurgery)
2) Neglected old left monteggia fracture
3) Multiple abrasion wound + laceration
wound over right pinna under ENT
Plan
- Peri ortho to review
- TCA 1/12 with XOA at ortho clinic
- Continue neurosurgery plan
1) STO day 1 over scalp
2) Continue IV Phenytoin and IV PCM
3) Make sure police report lodge
4) IV Cloxacillin 1g QID
5) Repeat CTB cm
- Continue ENT plan
1) To reassess patient once GCS is full
2) For scope prior discharge
3) No active ENT intervention