Mortality Case.pptx of mortality reportb

mortality report of healthcare setup

1. MORTALITY CASE DISCUSSION Dr Misbah Bukhari PG medicine

2. INTRODUCTION Patient name – Said Noor Age – 70 years old female DOA – 10/04/2025 Emergency At 2:15pm Presenting complaints 1)Severe headache 2) Vomiting 3) Loss of consciousness for past 4 to 5 hour

3. HOPI Patient was in usual state of health till afternoon when she developed Headache – sudden in onset, begins suddenly when patient came back from washroom, progressively worsening and reached to severe intensity within seconds, localized to occipital region with radiation towards neck and shoulders. VOMITING – 3 to 4 episodes over the period of 1 hour, projectile in nature and containing food particles After the onset of severe Headache with vomiting, patient become unconscious suddenly, but no associated complains of fits like activity, tongue bite,frothing.Urinary or fecal incontinence. No hx of deviation of angle of mouth or any weakness, speech disturbance or dysphasia , observed by attendents

4. PAST MEDIAL HISTORY T2DM for last 3 years , poor glycemic control HTN for past 15 years , not controlled with history of raised readings on and off IHD – Status post PCI with stenting done in 2020 History of Hep C positive and naïve to treatment PAST SURGICAL HISTORY Hx of right Total knee replacement 4 months back DRUG HISTORY Tab Sitaglumet 50/500mg once daily – Tab Covaltec 160/12.5mg OD non complaint Non compliant to with cardiac medication

5. FAMILY HISTORY – Hx of HTN , DM , IHD in parents No significant history of Aneurysm or ICB in first degree relatives No hx of polycystic kidney disease, connective tissue disorders or history of bleeding disorders in family PERSONAL HISTORY & SOCIOECONOMIC HISTORY Married with 4 children ,Housewife and lives with her family Patient was in up and about status , no history of smoking or any addiction

6. EXAMINATION Elderly lady lying in bed, in comatosed state , not responding to painful stimuli Vitals : BP 164/73 , Pulse 84/min , SpO2 72%at RA, Resp rate 25/min BSR 327mg/dl CNS : GCS 3/15 E1 V1M1, Pupils B/L mid constricted, Planters B/L Up going CHEST : B/ L NVB with B/L basal coarse crepts more marked on right lower zone CVS : S1+S2+0 , No added heart sounds, JVP not raised GIT : Abd not distended , soft on palpation and ,bowel sounds audible

7. MANAGEMENT Prop up position , Oxygen attached with NRM Double IV line passed , Airway secured by geudel airway and suctioning was done NG and Foley’s passed Blood CP, CRP , S.E , LFTS , RFTS sent chest X-ray and ECG was done Urgent CT brain plain advised Shifted to Medical ITC

8. CT brain plain showed -- Large ICB involving right frontal and parietal lobe with mass effect Leading to intraventricular extension with midline shift and sub arachnoid hemorrhage DIAGNOSIS : Massive ICB with Mass effect leading to midline shift Intraventricular extension with Subarachnoid hemorrhage. Attendents were counselled in detailed regarding disease and prognosis Code Status discussed: DNR & DNV signed

9. Several scoring systems are used in cases of intracranial hemorrhage to: Assess severity of the bleed
Predict clinical outcomes and disease progression
Guide management and treatment decisions

10. HUNT – HESS SCORE

11. ICH SCORING

12. Fischer Scoring

13. Patient was vitally stable , maintaining Sats at 94% e NRM Labs showed TLC 13, Hb 10.7, Neut 92, Plts 274k, CRP 1.3 Na 132, k 3.8, LFTs & coag profile N, Urea 44 , Creat 0.8 Management: Inj Mannitol 300ml IV stat then 200ml TDS Tab Nimodipine 60mg every 4 hourly Inf N/S 40cc/ hr Inj Risek 40mg IV OD Inj Rocephin 1g BD and IV flagyl 500mg TDS started Inj Insulin Humulin R sliding scale Observe for signs of raised ICP and worsening GCS

14. 10/04/2025 : At 6pm BP dropped to 80/40 – Bolus of 300ml N/S IV stat given At 11pm BP again dropped to 79/40 Boluses was repeated Mannitol was withheld due to hypotensive episodes Attendents were counselled regarding prognosis of disease

15. 11/04/2025 Day 1 Vitals: BP 118/60 , Pulse 63/min, Temp A/F, SpO2 94% e 10L with NRM , I/O – 2650/2000ml O/E GCS 7/15 E1V1M5, pt was localizing to pain stimuli Planters B/L up going, Pupils B/L small equal and not reactive to light Chest: B/L coarse crepts in middle and lower zones , more marked on R side Management: Continue mannitol Inj lerace 500mg IV BD Observe for drop in GCS and fits like activity

16. Neurosurgery dept was taken on board regarding surgical intervention EVD and evacuation CT angiography brain was advised Report showed M2 part of Right MCA is ecstatic measuring about 6.6mm with nipple sign present suggestive of aneurysmal bleed at that point Plan : Initially plan to go for EVD but due to risk of blockage and poor prognosis it was not done Manage conservatively, no surgical invention Physiotherapy advised & attendents counseling was done

17. 12/04/2025 DAY 2 Vitals : BP 124/62mmHg, pulse 78/min, SpO2 92% with NRM at 10 L Fever spike documented upto 101F GCS was static 7/15 E1V1M5, Chest showing B/L scattered crepts with conducting sounds Labs showed TLC 14.6,Neut 93, Plts 273k CRP 111 Na 134, K+ 2.9 ,Cr 0.8 , Urea 28 Plan = Continue with management plan Potassium replacement done – 2 ampoules in 500ml N/S over 4 to 5 hrs Continue Physiotherapy suctioning and TED stockings Attendents counseling

18. DAY 3 TO DAY 5 13/04/2025 to 15/04/2025 GCS remained static Vitally stable Management Treatment plan was continued as advised Attendents were counselled regarding patient condition

19. 16/04/2025 DAY 6 Patient condition detoriated GCS – 3/15 E1 V1 M1 , B/L planters Mute BP 177/86mmHg, SpO2 91%e NRM at 10L of O2 Pulse 110/min , Temp 101F Resp rate 26/min Labs – TLC 14.6, Hb 10,plts 321k, Na 157, Serum osmolality 292mOsm/L K 3.8, CRP 227, Urea 59 Cr 0.8 Management Inj meronem 1g IV TDS Mannitol was discontinued O.45% saline 500ml was started at 60cc/ hr Free water was advised through NG, 200ml every 6 hourly

20. 17/04/2025 At 6:30am Patient become hypotensive BP 87/47 -- MAP 56 Pulse 123/min Plan N/S 250 ml bolus given BP – 100/58mmHg

21. At 7:25am 17/04/2025 Patient suddenly collapsed , become pulseless and BP was not recordable No heart sounds , no breathing ECG was done showing Isoelectric line Pupils B/L fixed dilated not reactive to light No code blue announced as patient was DNR / DNV Death was declared to attendents . Cause of death Massive ICB with Intraventricular extension and subarachnoid hemorrhage Leading to cardiopulmonary arrest

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