DEATH AUDIT- DECEMBER 2016Dr. Sujay IyerI Year PGGeneral Medicine IV

PATIENT DETAILS Name: Mr. Kannan Age/ Gender: 73 years/ Male MR number: 16/403522 IP number: 16/061888 DOA: 18/12/2016 at 22:34 DOD: 23/12/016 at 13:40 Duration of Stay: 5 days.

PRESENTING COMPLAINTS Shortness of breath Giddiness Generalised weakness Easy fatigability Decreased urine output Vomiting

HISTORY OF PRESENTING ILLNESS Patient presented to the ER with complaints of

shortness of breath since 4 days, NYHA grade IV. H/O Vomiting 4 days back on consumption of

food. Non-projectile, non-billous, non-blood stained, consisting of food particles.

H/O increased frequency of micturition with poor urine output.

No H/O chest pain, palpitations, diaphoresis, syncope, orthopnea, PND.

No H/O fever, loose stools, abdominal pain. No H/O burning micturition, dysuria. No H/O cough with expectoration

PAST HISTORY K/C/O Hypertension since 6 years. On T.

Amlodipine 5mg P/O OD. K/C/O Old CVA, 6 years back. Resolved

completely.

Not a K/C/O Diabetes Mellitus, Bronchial Asthma, Tuberculosis, Coronary Artery Disease.

Not an Alcoholic or Smoker.

GENERAL EXAMINATION HR: 108/min. BP: 110/60 mmHg RR: 18/min. SpO2: 96% on room air. Temp: 99*F CBG: 112 mg%.

Pallor (++), Pedal edema (+) No icterus, cyanosis, edema,

lymphadenopathy.

SYSTEMIC EXAMINATION R/S: NVBS. No added sounds. CVS: S1S2 (+). No S3. No murmurs. P/A: Soft, non-tender, no organomegaly. CNS: Conscious, oriented. Left plantar - Extensor. Power - 5/5 in all 4 limbs.

INITIAL INVESTIGATIONSPATHOLOGY BIOCHEMISTRY OTHERSCBC:Hb – 4.0PCV – 14.2MCH – 18.1Plat – 2.31TC – 10,900

URINE ROUTINE:Albumin – TraceRBC – NilPus cells – 2 to 4Epithelial cells – 2 to 4Bacteria - Nil

RFT:Urea- 87Creat- 1.67

ELECTROLYTES:Na – 132K – 6.0Cl – 103

CARDIAC MARKERS:CPK T – 691CPK MB - 38

ECG:LBBB with tall T waves.

CXR:Increased bronchovascular markings.Normal lung parenchyma

ABG:pH – 7.40pO2 – 88pCO2 – 23HCO3 - 14

CHEST X-RAY

ECG

PROVISIONAL DIAGNOSIS Anemia for evaluation. Acute kidney injury with hyperkalemia.

INITIAL TREATMENT Inj. 10% Calcium Gluconate 10ml IV over 10 min. Inj. 25% Dextrose 100 ml with Inj. Actrapid 10 U

IV over 1 hour. Nebulisation with Salbutamol 1 respule P/N 1-1-1-. K-Bind Sachet 15 g in ½ glass of Water P/O 1-1-1. Transfusion with 1 unit of PRBC. Inj. Pantoprazole 40 mg P/O 1-0-0. T. Albendazole 400 mg P/O stat.

Admitted in A0 under GM IV because of unavailability of beds in MICU.

FURTHER PLAN USG Abdomen 2D ECHO Repeat Potassium after 4 hours. LFT Ca, Mg, Ph, Uric Acid Stool for occult blood and ova cysts Peripheral smear with reticulocyte count.

19/12/2016 Patient complained of easy fatiguability and

weakness. O/E:

HR - 112/min. BP – 100/60. RR – 22/min. SpO2 – 98%. I/O – 477/1000.

Pallor (++) Bilateral pitting edema (+) Occasional bilateral basilar crepitations (+)

Patient’s LFT was found to be elevated. USG abdomen was planned and MGE opinion was to be sought after.

Patient was shifted to MMW D4.

INVESTIGATIONSPATHOLOGY BIOCHEMISTRY BIOCHEMISTRYHb: 4.8

PERIPHERAL SMEAR:Microcytic hypochromic RBCs.Anisopoikilocytosis (+)Elliptocytes (+)TC is raised with neutrophilic predominance.Adequate platelets.No parasites.Reticulocyte count – 2%.

SEROLOGY: (-)

Urea: 80Creat: 1.3

Na: 131K: 5.1, 5.1

SGOT: 1830, 2710SGPT: 3270, 1942AlkP: 95, 111GGT: 83T.Prot: 6.0Alb: 3.8Glob: 2.2T. Bil: 0.9

Ca: 9.8Ph: 2.9Mg: 1.8Uric acid: 8.6

PT: 30.6 (13.5)INR: 2.42 PTT: 47.5 (32)

CPK T: 439CPK MB: 16

20/12/16 Patient was symptomatically stable. O/E:

HR: 110/min. BP: 110/80 mmHg. Pallor (++). Icterus (+). B/L Pitting edema (+). R/S: NVBS. Bil Crepts (+). More on left side.

Repeat CXR was advised. One unit of PRBC was transfused.

USG Abdomen: Mild fatty liver with GB wall edema. Bilateral simple

renal cortical cysts. Minimal left sided pleural effusion. MGE opinion: Hepatomegaly (+). ?Hemolytic cause

to r/o malignancy. ?HCC. To do LDH, AFP and CECT. To add Udiliv and Silybon & stop Propranolol.

TREATMENT DETAILS Inj. Furosemide 40 mg IV 1-1-0 Inj. Thiamine 100 mg IV 1-0-1 T. Rifaximin 400 mg PO 1-0-1 T. Propranolol 20 mg PO 1-0-1 (Stopped) T. Ferrous Sulphate 1 tab PO 1-0-1 T. B-Complex 1 tab PO 1-0-0 Syp. Lactulose 30 ml PO 1-0-1. Inj. Vitamin K 1 amp. IV 1-0-1. T. Udiliv 300 mg Po 1-0-1 T. Sliybon 140 mg PO 1-0-1.

21/12/16 Patient complained of hiccups. O/E:

HR: 106/min. BP: 110/80 mmHg. Pallor (+). Pedal edema (+). R/S: Bilateral crepts (+) P/A: Hepatomegaly (+)

2D ECHO: All chambers dilated. Severe LV dysfunction.

LVEF of 21%. Grade III Diastolic dysfunction. Trivial AR and TR. Global hypokinesia of LV. No RWMA. No clots. No vegetations.

Repeat CBC, RFT, SE were sent.

21/12/16 At 3 30 pm, patient developed high-grade fever

and dyspnea. O/E:

HR: 119/min. BP: 130/80 mmHg. Temp: 103*F. RR: 22/min. SpO2: 82% on room air and 99% with 40% FiO2.

R/S: NVBS. Bilateral crackles (+). ABG: Respiratory Alkalosis with metabolic

acidosis. (pH – 7.46, pCO2 – 23, pO2 – 136, HCO3 – 17)

ECG: No new ST-T changes. LBBB. Hb – 6.0. TC – 21,700. Plat – 73,000 (verbal). Na: 129. K: 4.9. Cl: 102. Urea: 68. Creat: 1.12

21/12/16 Impression: Sepsis. Anemia in failure.

Severe LV dysfunction. Thrombocytopenia for evaluation.

Patient shifted to sick cubicle in MMW D4. Oxygen support of 25% FiO2. Urine Routine, Blood and Urine C/S, Rapid

card test for Malaria, MP/MF and Dengue Serology sent.

Inj. Cefoperazone + Sulbactam 1.5 g IV BD started.

C. Doxycycline 100 mg PO BD started.

22/12/16 Patient’s dyspnea reduced. C/O Hiccups (+). O/E:

HR: 108.min. BP: 140/70 mmHg. R/S: Bilateral crackles reduced.

Inj. Metoclopromide 5 mg IV 1-1-1 added. Dengue serology (-). Malaria tests (-).

INVESTIGATIONS21/12/16 23/12/16

Hb: 6.0TC: 17,360Plat: 73,000

Urea: 68Creat: 1.12

Na: 129K: 4.9Cl: 102

Malaria (-)Dengue (-)Urine C/S: SterileBlood C/S: Coagulase negative Staphylococcus sensitive to all antibiotics except Penicillin & Tetracycline

Hb: 7.1Plat: 71,000

Urea: 41Creat: 1.19

Na: 132K: 3.1Cl: 99

ABG:pH – 7.06pCO2 – 56pO2 – 79HCO3 – 15.9

AFP (-)LDH (+) [4000]

23/12/16 Patient’s dyspnea reduced. Hiccups still (+). O/E:

HR: 123/min. BP: 110/70 mmHg. SpO2: 98% on 25% FiO2.

R/S: NVBS. Bilateral crackles decreased. HB: 7.1. Plat: 70,000. RFT and SE normal. Plan for Cardiology opinion post-rounds.

23/12/16 Patient found to be gasping. Call received

during rounds at 12:30 pm. HR: 132/min. SpO2: 85% with 60% FiO2 and

steadily falling. Peripheral pulse not palpable. CPR was immediately started according to

ACLS protocol. Patient was intubated with 6.5’ ET tube. CPR was continued. Patient was shifted to ICU for resucitation. Despite all efforts, patient could not be

revived and was declared expired at 13:41.

CAUSE OF DEATH CONGESTIVE CARDIAC FAILURE SYSTEMIC HYPERTENSION MICROCYTIC HYPOCHROMIC ANEMIA OLD CVA

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