AUGUST

MORTALITY
PRESENTION
Dr. Yvonne Sorviel Siilo
 Case Demography
• Name: Madam M.V

• Age: 54 years

• Status : CIV

• DOA: 29/07/23

• DOD: 02/08/23

• Number of days on admission: 5

 History- taken at the ER
PC Dizziness- 1/7
Palpitations-1/7

HPC • Patient was a known hypertensive (6 yrs., non compliant on

meds and resorting to herbal preparations) , has a history of a
CVA diagnosed 6 years ago (?hemorrhagic/ ischemic- does not
remember having a CT done or Tab soluble aspirin given)

• She was in her usual state of health when she started to

experience the above complaints for which she reported to the
hospital for further management.
 History cont...
ODQ;

• Easy Fatiguability Chest pain

• Exertional dyspnea PND, orthopnea
• Fever Pain on inspiration
• Malaise Headache
• Bitter mouth taste Chills
• Nausea Vomiting
Abdominal pain
Bipedal swelling
Anorexia
Dysuria, diarrhea, oliguria
 History cont...
• PM/SHx- Known hypertensive for 6 years, had a CVA (not known
whether ischemic/hemorrhagic), asthma -, diabetes-, epilepsy- ,sickle cell
dz-
• Previous admissions+ for stroke
• Surgeries--
• No hx of hemotransfusion

• Drug hx : Tab amlodipine 10mg od. Herbal medications (later discovered

that she was consuming herbal meds for weight loss)
 History cont...
• FHx- unremarkable

• Social hx : Patient is a retired trader, lives

with daughter at Osu, alcohol-, smoking-,
accepts blood transfusion, NHIS+
 Examination
• General exam- Middle aged woman , morbidly obese; weight
estimated to be 120kg with a height of about 170cm given BMI ~
41kg/m2 (Obesity class III)
• Propped up in bed at an angle of 45˚,
• Acutely ill looking and in respiratory distress evidenced by
respiratory cycles of 46 cycles/min SPO2 94% on room air
• Patient is not pale, anicteric, afebrile T-37.1˚, hydration status
satisfactory, no bilateral pitting pedal edema
• CVS- JVP not elevated, Pulse 114bpm- regular, good volume. BP-
252/131mmhg
• Apex beat not palpable, no thrills or heaves, S1+S2+M0
 Examination
• Resp- Air entry globally reduced, breath sounds vesicular, coarse
crepitations heard in the left lower lung zone

• G.I- Abdomen is obese, mwr+, soft, non-tender, 2 kidneys, liver,

spleen not palpable

• CNS- Grossly intact GCS 15/15

• Pupils are about 3mm, reactive to light.
Differential diagnosis
• Hypertensive urgency
• left lobar pneumonia
• ?P.E/ CCF 2˚ HHD
• ?Malaria
• Morbid obesity

Plan per ER team

1. Admit patient
2. FBC, BUE &CR, LFT, RDT, Widal test, Chest X-ray, ECG
3. Labetalol protocol
4. Tab Nifecard XL 60mg stat
5. BP recheck- 123/75mmhg
6. Supplemental oxygen therapy
 Investigations (done at sonotec)
CHEST X-
FBC BUE & CR LFT RAY
HB- 10.5 g/dl ↓ K- 4.3 mmol/l ↔ Bil. T- 14.01 umol/l 1. Possible
RBC- 4.3x 106 Na- 135.6 ↔ AST- 31 ↔ Cardiomegaly
ALT- 37 ↔ 2. Blunting of left
MCV- 73.3 fl ↓ Cl- 98.0 mol/l ↔ ALP- 159 ↔
PLT- 231x 103 Urea-3.0 mmol/l ↔ cardiophrenic angle
GGT- 65 ↑
WBC- 8.31x 103 CR-93 umol/l ↑ 3. Homogenous
Albumin- 34.88g/l ↓
eGFR-70mil/min/ opacification in left
1.73 lower lung zone
Widal Test RDT 4. Patchy opacifications
S typhi (O) 1/20 Positive for malaria ECG
S typhi (H) 1/20 parasites Sinus tachycardia with Left
ventricular hypertrophy
 Addendum
1. IV Ceftriaxone 2g od x48hrs
2. Tab Azithromycin 500mg OD x3/7
3. Tab Rosuvastatin 20mg nocte x 1/12
4. Tab Nifecard XL 60mg mane 30mg nocte
5. Supplemental O2 therapy
6. Tab Coartem 80/480mg BDx3/7
7. SC clexane 80mg OD
8. Check RBS- 8.3mmol/l
 Day 2 review
• Patient had no complaints
• No chest pain, no dyspnea, there was exertional dyspnea, no pnd, orthopnea, headache-,
fever-
• Patient kept removing non rebreather mask
• On examination
• Vitals- RR-42cpm
• O2 via NRM flowing at 3l/min with an SPO2 = 97%
• BP- 167/101mmHg
• P- 118bpm , regular with good volume
• T-37.1˚C
• Air entry reduced bilaterally on lower lung zones, breath sounds vesicular
• Rhonchi heard on all lung zones
• Patient had difficulty standing up from bed or even sitting up without support hence gait
could not be accessed
 Day 2 review
• GCS 14/15 Patient seemed a bit confused, patient oriented to person only but not place and
time
• Power 3/5 on all limbs
• All other examinations unremarkable

• Differential diagnosis
1. ?bilateral pneumonia:
r/o P.E
r/o M.I/CCF 2˚ HHD
2. Malaria
 Day 2 review
Plan+ Dr. Ruby
1. Lipid profile, FBS, HBA1C, Urine R/E, Echo, Cardiac troponins I & T, D-dimer
2. SC clexane 80mg BD
3. Tab azithromycin 500mg daily x 6/7
4. Nebulise salbutamol 5mg+ impratropium 0.5mg for 2 cycles
5. Tab clopidogrel 75mg OD x1/12
6. Tab Soluble Aspirin 75mg OD x1/12
7. Ct Tab coartem 80/480mg
8. Ct Tab Nifecard XL 60mg mane, 30mg nocte
9. Ct Tab losartan 50mg daily
10. Tab methyldopa 250mg BD
11. Monitor BP’s 2 hourly
12. Monitor urine output
13. Admit to ward
 Day 3
• Patient had no complaints
• Dyspnea+,Fever-, bowel movements+, abd pain-, easy fatiguability-, chestpain-,
frequency-
• Air entry a lot better than previously, breath sounds vesicular, no creps or rhonchi
heard

VITALS
• Febrile T-39˚C
• RR-48cpm
• O2 via non-rebreather mask at 11l/min with spo2 97%
• BP- 136/89mmhg P-110bpm, regular and of good volume
• Patient was unable to do labs but promised to get them done as soon as possible and
was also not able to get some medications due to financial constraints
 Day 3
DDx
1. Sepsis a.?UTI
b. ? Bilateral pneumonia
2. Malaria
3. ? CCF 2˚ HHD precipitated by
?bilateral pneumonia
?M.I
4. ?P.E

PLAN + Dr. Ruby

• To do blood c/s and retrieve other labs
• Tab Rabeprazole 20mg daily
• IV p’mol 1g 6hourly
• Nebulise with 5mg stat of salbutamol+ 0.5mg ipratropium bromide for 2cycles
 Day 3
• Liberal oral fluids aiming at 2l x24hours
• Monitor urine output
• Tepid sponging

Update later in the day;

• Total urine output for 24hours- 500mls concentrated with debris
?Acute renal failure
Plan
• Repeat BUE/CR this time at MDS-Lancet
• To hold Tb lorsatan
• To do 3L IV fluids over 24hrs( 1l N/S, 1LDNS, 1LR/L)
 Day 4
• Bilateral pitting pedal edema present up to the knee
• Both upper limbs now edematous as well
• Sacral edema could not be accessed
• Air entry was however better than previously, breath sounds vesicular with no added
sounds
Vitals
• BP- 124/81mmhg P-101bpm RGV
• RR- 40cpm
• SPO2- 97% on NRM flowing at 11l/min
• T- 39.4˚C
• Urine output less than 100mls concentrated with debris
• Patient was counselled on dialysis but they could not afford, labs were also yet to be
done
?obesity hypoventilation syndrome
?abdomen compartment syndrome
PLAN + Dr. Kumashie
• IV Lasix 40mg 6hourly
 Day 4
• IV amikacin 500mg bd
• Stop ceftriaxone and azithromycin
• SC clexane 80mg
• Serum Calcium and magnesium
• Stop aspirin and clopidogrel only if cardiac enzymes are negative
• Serum Calcium and Magnesium
• Stop IV fluids; just liberal fluids 1.5 to 2l
 Labs retrieved later during the day
Quantitative D- Blood C/S BUE/CR
Dimer
No bacterial growth after K- 5.4 mmol/l ↑
6.76 ↑ 48hrs Na- 135↔
Cl- 97.0 mol/l ↓
HBA1C Urea-23.3 mmol/l ↑
CR-520 umol/l ↑
6.3%
Urine R/E &C/S eGFR-8ml/min
Protein ++
Bacteria+
Leukocytes –
All other parameters normal
C/S- No bacterial growth
 Labs retrieved cont...
Cardiac troponins Lipid profile
I&T S-cholesterol 3.1mmol/l↔
I- <0.16 ng/ml ↔ LDL 1.0 ↔
T- 0.035 ng/ml ↑ (0-0.014) HDL 0.3 ↔
Non-HDL 2.8 ↔
S- Chol/HDL 10.3 ↑ (<4.1)
S- Triglycerides 4.01 ↑ (<1.70)
Day 4
• 11:20 pm
• Doctor on duty called to see patient
• Patient’s GCS had fallen to E4V1M2= 7/15
• SPO2- 92% on 15L/min O2 via rebreather
• T- 40˚C
• P- 70bpm rgv
• BP on right arm 187/149
• BP on left arm- 124/78
• RR- 56cpm with grunting sounds heard
• Urine output in 24hrs- 200mls
Day 4
Plan + Dr. Ruby
• IV paracetamol 1g stat
• Continue tepid sponging
• IV DNS 500mls to go slowly
• Pass NG tube for feeding
• Start IV hydrocortisone 12mg stat, 4mg 6hourly
 Day 5
• 4:30 am
• Doctor on Duty called to see patient who had stopped breathing
• SPO2 had suddenly dropped from 92% on 15l/min via non- rebreather face mask to
15%
• CPR was initiated by nurses and was done for 2 minutes
• However BP’s remained unrecordable
• T- 38.4
• Patient declared clinically dead at 4:30am

PLAN
• Inform relatives
• Prepare last offices
• Call the morgue
THANK YOU