This document summarizes the medical details of a 73-year-old male patient who passed away after being admitted to the hospital for 5 days. He presented with shortness of breath, weakness, and decreased urine output. During his hospital stay, he was found to have anemia, acute kidney injury, hyperkalemia, and severe left ventricular dysfunction. His condition deteriorated and he developed sepsis. Despite treatment, his respiratory status worsened and he died after going into cardiac arrest. The cause of death was listed as congestive cardiac failure, hypertension, anemia, and his history of stroke.

1. DEATH AUDIT- DECEMBER 2016
Dr. Sujay Iyer
I Year PG
General Medicine IV

2. 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.

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

4. 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

5. 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.

6. 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.

7. 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.

8. INITIAL INVESTIGATIONS
PATHOLOGY BIOCHEMISTRY OTHERS
CBC:
Hb – 4.0
PCV – 14.2
MCH – 18.1
Plat – 2.31
TC – 10,900
URINE ROUTINE:
Albumin – Trace
RBC – Nil
Pus cells – 2 to 4
Epithelial cells – 2 to 4
Bacteria - Nil
RFT:
Urea- 87
Creat- 1.67
ELECTROLYTES:
Na – 132
K – 6.0
Cl – 103
CARDIAC MARKERS:
CPK T – 691
CPK MB - 38
ECG:
LBBB with tall T
waves.
CXR:
Increased
bronchovascular
markings.
Normal lung
parenchyma
ABG:
pH – 7.40
pO2 – 88
pCO2 – 23
HCO3 - 14

9. CHEST X-RAY

10. ECG

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

12. 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.

13. 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.

14. 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.

15. INVESTIGATIONS
PATHOLOGY BIOCHEMISTRY BIOCHEMISTRY
Hb: 4.8
PERIPHERAL SMEAR:
Microcytic hypochromic
RBCs.
Anisopoikilocytosis (+)
Elliptocytes (+)
TC is raised with
neutrophilic
predominance.
Adequate platelets.
No parasites.
Reticulocyte count – 2%.
SEROLOGY: (-)
Urea: 80
Creat: 1.3
Na: 131
K: 5.1, 5.1
SGOT: 1830, 2710
SGPT: 3270, 1942
AlkP: 95, 111
GGT: 83
T.Prot: 6.0
Alb: 3.8
Glob: 2.2
T. Bil: 0.9
Ca: 9.8
Ph: 2.9
Mg: 1.8
Uric acid: 8.6
PT: 30.6 (13.5)
INR: 2.42
PTT: 47.5 (32)
CPK T: 439
CPK MB: 16

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.

17. 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.

18. 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.

19. 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

20. 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.

21. 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 (-).

22. INVESTIGATIONS
21/12/16 23/12/16
Hb: 6.0
TC: 17,360
Plat: 73,000
Urea: 68
Creat: 1.12
Na: 129
K: 4.9
Cl: 102
Malaria (-)
Dengue (-)
Urine C/S: Sterile
Blood C/S: Coagulase negative
Staphylococcus sensitive to all
antibiotics except Penicillin &
Tetracycline
Hb: 7.1
Plat: 71,000
Urea: 41
Creat: 1.19
Na: 132
K: 3.1
Cl: 99
ABG:
pH – 7.06
pCO2 – 56
pO2 – 79
HCO3 – 15.9
AFP (-)
LDH (+) [4000]

23. 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.

24. 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.

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

26. THANK YOU