This document summarizes the hospitalization and death of a 71-year-old female patient who presented with right knee pain and a fractured humerus. During her hospital stay, she developed acute kidney injury, anemia, suspected heart failure, and was found to have a colon mass. Her condition deteriorated and she passed away. The final diagnoses were suspected heart failure, acute kidney injury, anemia, and colon mass. Areas for potential improvement and differential diagnoses are not specified.

1. Mortality – Morbidity Report
Department of Medicine,
Gladstone Hospital

2. MORTALITY

3. A 71-year-old female r/o Gladstone, QLD
DOA - 06/03/23, seen by ED at 12:36 hrs
DOD - 22/03/23
Chief complaints:
• Was not able to cope at home because of Rt knee pain and had fracture of
head of right Humerus on 03/03/2023 when she had a fall at home, which
were being managed conservatively with collar and cuff with analgesia
• Also had bouts of diarrhoea? Antibiotic induced was Trimethoprim due to
presumed UTI (not evident on Urine MCS)

4. Past Medical History
• Post Fracture of head of right humerus after fall on 03/03/2023
(conservatively managed)
• Hypercholesterolemia on Atorvastatin
• T2DM Complicated by Right Charcot Foot on Metformin and Insulin
• Hypertension on Perindopril and Amlodipine
• COPD on Tiotropium and Oldaterol
• Hypomagnesemia On Magnesium

5. Examination
GENERAL EXAMINATION
• Palor +/Icterus-/ LAP- /Pedal Edema
++/Cyanosis-
• Vitals
• HR - 74
• BP- 125/86 mmHg supine
• Temp - 36.7 C
• RR - 20/min abdominothoracic
• SPO2- 92% on 2 Litres via NP
• JVP not mentioned
• Dehydrated???
SYSTEMIC EXAMINATION
• CNS- Conscious, oriented to
time/place/person. No neurological
deficit
• CVS-S1,S2 Heard ,No Murmur present
• P/A- Soft non tender , no
organomegaly
• R/S- Clear, no adventitious sounds.
• Stage 2 pressure area noted in sacral
and coccyx region with macerated
skin.

6. Investigations/Day 1
• Hb/WCC/PLT - 81/7.8/293000
• UREA/eGFR - 10.8/24
• Na/K - 124/4.8
• Bil(T/D) - 9/4
• AST/ALT/SAP - 26/28
• PROT/ALB - 53/22
• Covid RAT - Negative
• CXR showed the heart is mildly
enlarged, Pulmonary vasculature is at
the upper limits of normal. Bronchial
wall thickening is present, the lungs and
pleura are clear.

7. Provisional Diagnosis by ED
• Multifactorial Functional decline needing increased care needs in context of
diarrheal illness
• Decreased Mobility due to Rt Shoulder and Rt Knee pain
• Suboptimal COPD control
• Fluid Overload?
• Carers Fatigue
• Hearing Difficulty using hearing aid

8. Additional Diagnosis and Treatment By Medical Team:
(06/03/2023 at 15.55 hrs)
• Acute Kidney Injury Secondary to Multifactorial including Dehydration
(ongoing Diarrhoea) and Drugs including ARB and Metformin
• Anaemia
Treatment :
• Started on IV fluids 1 litre over 24 hours
• Haematinics sent at admission by medical team
• Metformin and Perindopril withheld in view of AKI

9. DAY 1 DAY 3 DAY 5
Hb/Tlc/PLT 76/8.0/203000 82/7.0/242000 83/7.6/279000
Urea/eGFR 10.8/24 9.9/27 10.9/28
Na/k 124/4.8 128/5.0 125/5.2
CRP Not available 136 88
Blood C/S - - -
Stool Sample MCS Negative
Urine MC/S done on
03/03/23
negative

10. Management/Day 1: (07/03/2023 at 10:50 hrs)
• Urine and Stool MCS were sent, which came back negative
• Chest X ray was planned if need for oxygen increased (currently 92% at
2 litres of oxygen via NP)
• Pt was referred for fracture clinic due to right humeral head fracture
• Bloods were repeated in morning, were followed at 13.24 hrs same day
Hb dropped to 70 from 76gm, CRP levels 170. It was decided to
transfuse 1 unit of blood and start patient on IV empiric antibiotics due
to raised CRP (unspecified infection focus), VTE prophylaxis was
modified in view of worsening eGFR, Pt was given more fluids.

11. Day 2: (08/03/23 at 9:30 hrs)
• Pt was found to have Iron deficiency: was transfused IV iron Polymaltose the
same day
• In view of decreased haemoglobin, Non Contrast CT Abdomen was planned
along with surgical referral for endoscopy and colonoscopy (CT happened on
09/03/2023 reporting was delayed till 12/03/2023)
• Also planned for CXR which showed signs of pulmonary oedema and patchy
consolidation at left base
• Pt remained stable, same evening (time not clear from notes), when pt
developed hypothermia with iron transfusion still ongoing, it was escalated to
on call PHO, same was discussed with Consultant, Iron Infusion stopped at
1830hrs

12. • On 09/03/2023, 11.00 hrs Pt felt better, CRP was noted 114, additional diagnosis of CAP
and HF was made (evident on recent CXR)
• Pt was started on IV furosemide 40 mg x 2 days (I/O and daily weight charting was
advised) IV Fluids were stopped, ECHO was arranged as an Outpatient
• Pt was reviewed by medical team on 10/03/2023 at 10:40 hrs, noted to have decreased
Sodium levels and raised blood pressure (180/92mmhg), Amlodipine was increased to
10 mg from 5 mg OD
• Same day at 1430 hrs, CT scan report (provisional report) was noted to have a mass in
caecum which may represent a frank neoplasm. Decision was made to further scan with
oral contrast and in view of the recent findings of CT scan, family meet was pondered

13. • Pt was reviewed on 11/03/2023 at 11:15 hrs was better QADDS=0, Nil O2 requirement.
Bloods noted to have Na 123, furosemide was stopped and fluid restriction in place now upto
1200ml. Decision to evaluate TFT was made came back normal.
• Pt. remained stable with intermittent oxygen of 0.5 litres via NP.
• CT abdomen with oral contrast showed mass lesion in ascending colon (final reportage).
• Surgeons were notified for a colonoscopy (in view of CT findings), HDU was notified of pre
anaesthetic assessment who advised for further diuresis and ECHO and asked to wait as pt
still requiring oxygen intermittently pt was stable till 15/03/2023.

14. Already 10 days in hospital contd.
• On 15/03/2023, CXR was noted to have bilateral pleural effusion,
consolidation with collapse was done in view of persistent need of oxygen
• Further furosemide dosage was increased to BD and Piptaz was introduced in
view of consolidation
• On 18/03/2023, Pt was seen at 16:20 hrs - PHO saw the patient stable,
sodium was noted to be 127 (improved), GFR 36 ? New baseline (earlier
baseline was 45), Hb 95 gm CRP dropped to 17. Now Pt was planned for
colonoscopy on 21/03/2023, if cleared by Anesthetist and remained stable

15. DAY 7 DAY 9 DAY 10
Hb/Tlc/PLT 78/8.6/287000 91/8.4/278000 96/7.1/252000
Urea/eGFR 14.8/39 17.9/42 19.5/39
Na/k 123/5.5 122/5.0 127/4.2
Bili/Dir 6/4 7/4 7/4
ALT/AST 29/24 24/17 24/19
CRP 62 60 20

16. • Pt remained stable till next day, when nurses notified of hypothermia (34.6)
to the on-call PHO, <no notes? Workload weekend>, on 19/03/2023
• Med team saw the patient on 20/03/2023 at 0845 hrs, Pt remained stable,
decision to cease antibiotics and furosemide was reduced to OD (oral), Pt
awaiting colonoscopy, Anesthetist reviewed the pt (ECHO still not available,
could not be done -?long weekend)
• Nil notes by med team on 21/03/2023: day of colonoscopy ? May be due to Pt
being in OT - not clear with notes.

17. On 22/03/2023 at 01:39 hrs
• Pt developed hypothermia, was seen by ED team at night, Nil
complaints mentioned by the patient except feeling cold feet (already
having bear hugs), vitals remained stable - BP 130/65, HR 50 bpm,
temperature 33.2, RR 20 bpm, O2 94 % on 3 litres of oxygen via NP
(prior to this Pt was not on oxygen) chest developed bibasal crepts.
• Pt was continued on oxygen, put on IVF at 80 ml/hour and continued
with bear hugging
• Pt was re evaluated at 03:54 hrs by ED team as nurses alerted them that
the Pt was wet in the chest ? Volume overload, on chest auscultation
wide spread crackles were noted. Pt was given stat 40 mg of
furosemide, ceftriaxone 1 gm stat with metronidazole stat? reason? CXR
was advised too

18. Contd.22/03/2023
• MET call was pressed, timing not clear with the notes, due to low saturation
around 70 percentage on 3 litres of oxygen via N.P, Pt gasping already, ARP
consulted not for CPR and ICU based cares, GCS 3/15 Medical Consultant was
made aware
• Family was informed, all active treatment ceased, Pt was given IV hyoscine
and shifted to single room
• Pt passed away at 5:40 hrs. RIP

19. Final Diagnosis:
• Suspected Heart Failure (History of hypertension,T2DM, CKD, sepsis, vol.
overload)
• AKI On CKD ( secondary to Dehydration, ARB)
• Anaemia transfused bloods and IV Iron
• Post Fracture of head of right humerus after fall on 03/03/2023
(conservatively managed)
• Hypercholesterolemia on Atorvastatin
• T2DM Complicated by Right Charcot Foot on Metformin and Insulin
• Hypertension on Perindopril and Amlodipine
• COPD on Tiotropium and Oldaterol
• Hypomagnesemia On Magnesium

20. What else could have been done?
• ?
• ?

21. Differential Diagnosis
• ?
• ?

22. Thank you!