2. Bio-data
• Patient: K.I
• Age: 55 years
• Gender: male
• Village: SEETA
• Religion: MOSLEM
• Date of admission: 20th/JAN /2024 13:20HR
• Date of demise: 20th/JAN / 2024 17:04HR.
• Time spent; About 4hrs
3. 20/01/24 13:20hr at emergency Dep’t (MO)
• 55 yr old male with back ground hx DM/ HTN ambulating on Sc mixtard
basing on RBS , however on unknown Anti-hypertensives.
• p/c; sudden loss of consciousness x 6HRs.
• HPC
- Patient had been well Until 6Hrs when he suddenly Lost consciousness.
- This preceded by generalised headache, no convulsions , no vomiting , no
vision or speech disturbance prior to loss of consciousness.
- No prior Hx of cough , DIB OR chest pain reported.
- No prior Hx of palpitation , easy fatigability or exertional dyspnea
neither was there generalised body swelling.
R.O.S…….. Unremarkable
4. Cont…
• PMH; Unknown HIV serology , with background hx of DM/ HTN long standing ,
however good adherence to medication as reported.No other chronic illness.
• PSH; No hx of surgical procedures or BT, or hx of trauma.
• FSH; No Clear Family Hx of cancers reported , Doesn’t smoke or consume
alcohol.
• O/E- Unconsciousness , febrile 41.6c, no pallor, no jaundice, no edema, or
Dehydration noted.
• BP 167/71 Mm Hg PR 108bpm SPO2 98% 10l/min NRM. RBS 19.5mmol/l
• RS SPo2 98% NRM with transmitted sounds bilaterally , no other added sounds.
• CVS; PR 108bpm normal vol regular Bp 167/71MmHg .
• Hs 1 +2 heard Normal.
• CNS GCS 4/15(unconscious) E- 1 ,
• V- 2
• M – 1 , neck is soft.
5. Cont…
• CNS …Pupils ; R = Constricted.
• L = sluggish reactive to light 4mm.
• Power R < RUL ..2/5
• RLL…2/5
• L < LUL ..1/5
• LLL…1/5
• DX..55/M known DM/HTN with
• 1)CVA? HEMORRHAGIC STROKE.
8. Laboratory Cont . . .
FBC Ranges
Basophils % 0.4 % 0.0 - 0.5
Neutrophils # 7.77 ** 10^3/ul 2.00 - 7.50
Lymphocytes # 1.80 10^3/ul 1.50 - 4.00
Monocytes # 0.44 10^3/ul 0.20 - 0.80
Eosinophils # 0.01 ** 10^3/ul 0.04 - 0.40
Basophils # 0.04 10^3/ul 0.20 - 0.10
Blood Group O Rh (D) Positive
Haemo Parasites tests
Malaria microscopy No malaria
parasites seen
More than 10 in
every HPF
9. At EMD(Admitting MO )
• Admit the patient in HDU, PUT on O2 Therapy 10l/min NRM.
• Discuss with caretakers about need for ICU (Failed to get space in other
hospitals & Decision made for the patient to stay.)
• IV pcm 1g tds alternate with morphine 5mg
• IV Phenytoin 1g stat , then 250mg BD
• IV omeprazole 40mg
• IV ondansentron 8mg
• IV Mannitol 20g
• Do Tapid sponging PRN, & keep in lateral recumbent position with 2hrly bed
turning.
• DO Brain CT Scan , do CBC , GXM PT/INR RFTs & B/S for MPs.
10. 05:04pm SHO
• Called to review patient,
• Noted a 55/m admitted 4hrs ago with hx of HTN/DM & with GCS
4/15.patients family couldn’t afford ICU hence opted for HDU.
• Unfortunately the nurse team was called by family that the patient was
no longer breathing .nurses called the Team on call.
• Found patient unresponsive, cold with no pulse, no resp effort, no
corneal reflex, pupils dilated and death confirmed at 05;04pm
• Possible cause of death; Cardio-Respiratory Arrest secondary to
Haemorrhagic stroke
11.
12.
13.
14. Discussion (swiss cheese model)
i) Patient factors;
ii) Systemic factors; Policies, Check list, Training
iii) Personel factors; Education - Communication –Intervention
Patient factors
• Patient was a known DM/HTN hence comorbidities.
• Pts Bps and RBS readings were high signifying poor control.
• This was a very high risk patient for Neurovascular events and it was
wise to have a high index of suspicion.
15. Discussion Cont . . .
Systemic factors
• Policies are in place at emergency
• Trainings are held. How regular?
• Check list is there at emergency.
• Whats the criteria for ICU admission
• And what was the goal of care ? Is it palliative
Factors pertaining to us
• Diagnosis & intervention was it the right??
• Communication; timely communication for a member of the surgical team to review
prior to admission.
• GCS of 4/15 wasn’t questioned. with BRAIN CT READING.
• Primary Doctor at emergency not fully involving the specialty team before admitting.
• Unclear documentation . No CT or LAB results mentioned/recorded, Not quoted the
neurosurgeon anywhere yet managed to talk to him.
16. Was the death preventable?
• Possibly NO.
Take home
• Utilizing history and clinical picture as useful diagnostics.
• Early consultation and intervention
• Active monitoring
Editor's Notes
Time of arrival at emergency 5.25pm, one reading of vitals at emergency at 9.08pm about an hour before the patient’s passing, which means unfortunately we lost her as soon as she reached the ward.
There was only one monitored vital ever recorded.
