INTERNAL MED-MORTALITY AUDITS final.pptx
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The document presents a mortality audit for January 2024, detailing 83 cases with 8 fatalities, highlighting various diagnoses including strokes, pneumonia, and cancer. Key cases are documented, providing patient demographics, medical histories, and treatment plans, some culminating in clinical death. The report emphasizes the management of complex health conditions, including infectious diseases and complications from chronic illnesses.
INTERNAL MED-MORTALITY AUDITS final.pptx
- 1. JANUARY MORTALITY AUDITS INTERNAL MEDICINE 01/02/24 1
- 2. ER OVERVIEW-JANUARY • Total number of cases= 83(25-detention,58-admission) • Total number of mortality= 8 • Total number of referrals =8 • Total number of discharges= 47 • Total number of trans-outs=20 2
- 3. NAME AGE SEX DOA DOD DIAGNOSIS R.A.N 42 F 29/12/23 1/1/24 ?Infarctive stroke r/o cerebral Toxoplasmosis in RVI P.A 53 F 2/1/24 4/1/24 1. Bilateral Lobar Pneumonia 2.Cardiogenic shock 3.Recurrent hypoglycemia 2 ?addisonian crises E.O 56 F 2/1/24 3/1/24 Retroviral infection Complicated with Left lobar pneumonia, r/o PTB, Severe Anemia C.O.T 62 F 4/1/24 7/1/24 1. Decompensated CCF in a known HFrEF secondary to HHD ppt atrial fibrillation 2. Cardiogenic 3
- 4. NAME AGE SEX DOA DOD DIAGNOSIS J.D 63 M 13/1/24 18/1/24 Prostate Cancer with metastases to Liver and ?Brain Severe Anemia A.K-S 67 M 20/1/24 21/1/24 1. Cirrhosis 2. ? Hepato-renal syndrome 3. Cardiogenic shock Known case of - chronic alcoholic liver disease - dilated cardiomyopathy / Atrial fibrillation 4
- 5. NAME AGE SEX DOA DOD DIAGNOSIS G.L 83 F 24/1/24 25/1/24 Acute left ventricular failure Ppt by lobar pneumonia in a known hypertensive and diabetic E.N.T 68 M 26/1/24 29/1/24 1. Stroke 2. Intestinal obstruction AKI r/o CKD 3. ?Hepato-renal syndrome 5
- 6. CASE 1 R.A.N 42YRS FEMALE, TIME: 29-DEC-2023 06:25 PM • Patient brought to the OPD by relatives with a week hx of weakness, drooling • Patient said to have been unwell for the past two weeks • Has been having intermittent episodes of boils prior to this presentation • Patient had had complained of dizziness and easy fatigability • Was rushed to the hospital when she suddenly became aphasic, drooling saliva with change of gait • Was initially sent to another facility last week where she was admitted for one week • Relatives are unable to give much information about diagnosis since they were not there • Medical hx; no known chronic medical condition • Shx; divorcee, has one child who passed at three years old • odq; ROH-, smoking-, vomiting+, headache+ 6
- 7. On examination patient seen • aphasic , not aware of person, place and time , facial asymmetry GCS E 4 V1 M5 10/15 • has transmitted sounds in all lung zone with reduced air entry in lower lung zones • BP 110/76mmhg, pulse rate is 101bpm • abdomen is soft, mwr, non tender head CT scan done at medylife 17/12/23 • no structural intracranial abnormality is demonstrated IMP: ? immunosuppression • r/o cerebral toxoplasmosis • ? infarctive stroke • ? ICSOL • ? aspiration pneumonia 7
- 8. Review: TIME: 30-DEC-2023 12:31 PM • 42 year old divorcee • 3 year old passed away due to medical complications ?? • presented with weakness , drooling and aphasia • has a hx of weight loss, frequent boils and persistent skin rash • Previous head Ct scan showed no hemorrhage 8
- 9. Review: TIME: 30-DEC-2023 12:31 PM • Patient seen today • passing lose stools • afebrile, anicteric • has generalized maculopapular rashes with erythematous bases • GCS E 2 V 1 M 5 8/15 • pupils about 1 mm in diameter, respond minimally to light • breath sounds vesicular • air entry reduced in lower lung zones • abdomen is soft, mwr, non tender 9
- 10. Investigations lab results • chloride 99 creatinine 100.7 potassium 2.88 sodium 142 urea 5.68 • LFT albumin 43.8 AST 122.7 ALT 161.8 GGT 94 • wbc 18.1 lymph 10.2 gran 6.7 HGB 6.5 normocytic normochromic anemia • Initial HIV screen : NR repeat on 1/1/24 reactive • HEP B &C NR 10
- 11. Addendum with Physician consultant on phone TIME: 30-DEC-2023 12:58 PM To manage as a case of • 1. Infarctive stroke with sepsis • 2. Septicemia with brain abscess • 3. Anemia of chronic disease • ??retro (retroscreen was non reactive on 29/12/23) Plan • IV ceftriaxone 2g daily • Iv flucloxacillin 500mg 6hrly • Iv metronidazole 500mg 8hrly • tab clopiodgrel 75mg daily • tab piracetam 800mg bd • possible referral to korle bu teaching hospital by Monday ADDENDUM- 30-DEC-2023 10:22 PM • PATIENT WAS SAID TO HAVE HAD SEIZURE AND WAS GIVEN DIAZEPAM 10MG ST 11
- 12. Review 31-DEC-2023 11:19 AM Case of ?Immunosuppression in a middle aged woman • being managed for infarctive stroke • awaiting transfer to KBTH tomorrow , patient still unable to talk • not well oriented • oe , p- j-afebrile edema cvs: BP110/70 res; c/c abd: nad cns: not well oriented, having tremors • Input 2400mls output in diapers • Plan • Repeat Retroscreen at Lancet , Hep B and C, • Input 2500mls n.s , please pass catheter for output monitoring , if output more than 30mls/ hour to start on IV KCL • continue treatment ADDENDUM 31-DEC-2023 06:53 PM • 40 mmol (= 3 ampoules of 10 ml of 10% KCl) in one litre of 0.9% sodium chloride, to be administered over 4 hours. Do not exceed 10 mmol/hour. 12
- 13. Review: TIME: 01-JAN-2024 01:03 PM Patient with Right Hemiplegia in an Immunocompromised patient, • patient had two seizures this morning , tonic clonic seizures aborted by itself • oe :p- j-afebrile, patient having maculopapular rashes with papular pruritic rashes on limbs cns: GCS e4 V1M5 10/15 .not moving the right limbs • Plan • Repeat Retroscreen, Repeat CT-scan Head with contrast • IV KCL 40mmol daily • Tab Setrin 1920mg od • prepare for referral 13
- 14. DOD: 01-JAN-2024 11:10 PM CALLED TO SEE PATIENT WHO WAS SAID TO BE DESATURATING OE • NO SPONTANOUS CARDIOPULMONARY ACTIVITY • NO PERIPHERAL OR CENTRAL PULSE • NO HEART SOUNDS, NO BREATH SOUNDS • PUPILS DILATED AND FIXED • IMPRESSION • CLINICAL DEATH PLAN • PERFORM LAST OFFICES, INFORM RELATIVES, MOVE BODY TO THE MORGUE 14
- 15. CASE 2 P.A 53YRS FEMALE TIME: 02-JAN-2024 05:15 PM Pc: Severe Epiagstric Pain X Vomiting And Diarrohea X 1 Day Prior To Presentation Pmhx: Known Pud Patient , Odq: Heart Burns+, Nausea+, Periumbilical Pain- , O/E : Obese Patient In No Obvious Respiratory Distress, Not In Pain , P- ,J-, Bilateral Lower Limb Hyperemia With An Ulcer Measuring 1cm ,Patient Has Cold Extremities Imp: Dehydration Sec To Infective Gastroenteritis Acute Exacerbation Of Pud Plan • Detain Patient • Fbc , Bue And Cr, Bf For Mps , Typhoid Igg/Igm, H.Pylori • Iv Omeprazole 80mg Stat Iv Paracetamol 1g Stat • 1l Dns 15
- 16. ADDENDUM TIME: 02-JAN-2024 08:28 PM • 3,500 PARASITES PLAN • IV ARTESUNATE 500MG AT 0, 12 ,AND 24 HRS • CT ORAL AFTER IV • PARACETAMOL 1G TDS • OMEPRAZOLE 40MG BDS X 14 DAYS • NUGEL O 15 MLS TDS ADDENDUM TIME: 02-JAN-2024 08:48 PM • IV PARACETAOL 1G TDS • IV METOCLOPROMIDE 10MG BDS • SC CLEXANE 80MG OD 16
- 17. ADDENDUM : 02-JAN-2024 09:16 PM • HYPEREMIA IN BOTH LOWER LIMBS , FROM KNEE TO CALCANEOUS • 1 CM ULCER ON THE RIGHT LOWER LIMB • ADD CEFTRIAXONE 2G OD • TO DO DOPPLER ULTRASONOGRAPHY CALLED TO SEE A PATIENT 03-JAN-2024 03:53 AM • BEING MANAGED FOR INFECTIVE GASTROENTERITIS, ACUTE EXACERBATION OF PUD, CELLULITIS OF RIGHT LEG, SEVERE MALARIA O/E • MORBIDLY OBESE FEMALE, ACUTELY ILL, IN RESPIRATORY DISTRESS (SPO2-67% VIA FACE MASK), LITTLE URINE IN THE CATHETER BAG, SKIN IS SCALY • BP READINGS NOT STABLE, BUT BOTH BPS (85/56MMHG) AND PULSE (42) ARE LOW • RESP: AE DECREASED, BS VESICULAR, NO BASAL CREPS • CVS: HS 1+ 2+ M0, PERIPHERAL PULSES DIFFICULT TO PALPATE • CNS: CONSCIOUS, GCS= 14/15 • REVIEW OF LABS • BUE & CR: EGFR= 18 ML/MIN/1.73M2 PLAN • KEEP HEAD END OF BED RAISED • CT FLUID RESUSCITATION- 2L NS, 1L RL • 2 HOURLY URINE MONITORING, MONITOR BP, SPO2 AND PULSE CLOSELY • IV CLINDAMYCIN 600MG TDS X 24 HOURS • CT OTHER MEDICATIONS • ADRENALINE ON STANBY • HYDRATE PATIENT. SLOWLY GIVE IV FLUIDS 17
- 18. REVIEW IN THE MORNING IME: 03-JAN-2024 07:31 AM • C/O; HEADACHE, DID NOT SLEEP THE ENTIRE NIGHT • O/E: • MORBIDLY OBESE FEMALE, ACUTELY ILL, IN RESPIRATORY DISTRESS, ABOUT 150ML URINE IN THE CATHETER BAG • BP= 57/33MMHG P= 44 SPO2= 98 ON NRM • RESP: AE ADEQUATE, BS VESICULAR, NO BIBASAL CREPITATIONS • CVS: HS 1+ 2+ • PLAN • HOLD REMAINING IV FLUIDS • CT OTHER MANAGEMENT 18
- 19. Review TIME: 03-JAN-2024 10:53 AM • 53yrs old • hx of CCF 2 HHDX, on amlodipine 10mg, losartan 50mg • hx of PE completed 6mths of warfarin • apparently well until yesterday morning when she started complaining of burning sensation in the legs • then started vomiting, x5 and having abdominal pain • daughter rushed her here • labs: • shows malaria • high creatinine 265, others normal egfr 17.4 • LDL 0.90, TC 3.08.HDL 1.87 • wbc 7.4 hb 14.8 granulocytosis 19
- 20. complains of headaches, dizziness • noticed to be vomiting this morning o/e morbidly obese, afebrile, in mild resp distress, bilateral pitting edema to the knee • spo2 on oxygen 14/min 81% • bp 117/77mmhg • p 75bpm • chest ae reduced bilaterally, • abd soft, wmr, Nontender • CNS 15/15 • s/l blisters formation on the right leg • problems • acute respiratory distress r/o PE, CCF r.o cardiogenic shock • poor kidney fxn r/o AKI r.o cardio-renal syndrome • obesity type II • malaria 20
- 21. plan • reduce artesunate to 420mg (based on last wt 175Kg in august) • to do ctpa • stop clexane o/a poor renal fxn • iv lasix 60mg tds x 48hrs • iv heparin 5000iu st then 1300iu/hr • ecg, cxr • hbac1, retroscreen • bilateral venous doppler of the legs • echo when stable • dietician review • ivf 1.5L NS • strict input and output chart • abd pelvic usg- ?renal parenchymal dx 21
- 22. on discussion + Physician specialist • to consider • severe dehydration o/a low bp • r.o cardiogenic shock • obesity hypoventilation syndrome • plan • continue current mgt • encourage oral intake • cardiac troponin I 22
- 23. Review 04-JAN-2024 09:46 AM • case of severe dehydration r.o cardiogenic shock • obesity hypoventilation syndrome • ?PE r/o MI • ECG/; HR 124bpm., narrow qrs complexes • developed hypogylycemic episodes yesterday- not a known DM • input 2600mls • output 650mls • bp 114/97mmhg • p80bpm • spo2 on oxygen via NRBmask fluctuating • rbs 9.1mmol/l • labs pending • CTPA pending 23
- 24. • iv cannula site was noticed to be bleeding thus heparin wasnt served • o/e morbidly obese woman, in resp distress, spo2 on oxygen not recording >40%, bilateral pitting odema, buffalo hump, onchronosis • chest anterior chest: ae in reduced in lower lung zones bilaterally, vesicular, no creps/rhochi heard • abd full, mwr, nontender • cns restless, conscious, alert • blisters formation of the right leg problems • unresolved acute resp distress • hypoglycemic episodes ?cause • ?bleeding disorder • hypovolemia • chronic steroid abuse- features of Cushing syndrome imp: • case of severe dehydration r.o cardiogenic shock • obesity hypoventilation syndrome • ??addisonian crises 24
- 25. • plan • to pass ng tube for feeding • INR, Hba1c, repeat buecr, retrieve all pending labs • to discuss with specialist Report: • Serial axial CT scan images of the chest with contrast administration show no aortic aneurysm , dissection or pulmonary embolism. images show residual consolidation seen posteriorly on the left along the lower lobe sand residual pleural thickening seen bilaterally. There is also limited ground glass opacification. There is hiatus herniation seen along cardiac orifice of the esophagus . Images show no effusion . Normal trachea and bronchial airways. • Imp: • Residual consolidation and pleura thickening as described with evidence of hiatus hernia . No pulmonary embolism is seen. Cardiac enzymes: CK-MB 143.4 H Others normal Cardiac troponin I<0.16 25
- 26. Addendum TIME: 04-JAN-2024 11:21 AM • client very restless • sp02 on oxygen via facemask nrb <30% • bps on cardiac monitor not reading • electrodes attached to cardiac monitor • noticed to be taking deep breaths with spontaneous cessation of breathing • no cardio pulmonary activity seen • central pulses absent • CPR initiated • ECG on cardiac monitor shows asystole • pupils fixed and dilated • unresponsive to pain • imp clinically dead at 10:00am • plan • inform specialist and relatives • deposit body to morgue 26