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1. CONTINUOUS QUALITY IMPROVEMENT DURATION OF STAY 2 DAYS

2. A 71  yr old morbidly obese lady was brought to the emergency room with chief complaints of:                          CONSTIPATION since 5 days            INABILITY TO SIT OR STAND ON HER OWN since 3 days HISTORY OF PRESENTING ILLNESS: Patient was apparently normal ,then complaints started as: Constipation since 3 days, not associated with any abdominal pain/fever/ vomitings and able to pass flatus. H/O self fall  3 days back during night, following which she's unable to sit or stand on her own and not able to move her rt lower limb since then.

3. No C/O headache ,LOC, involuntary movements, involuntary passage of urine, deviation of mouth C/O SHORTNESS OF BREATH GRADE 3 since 4 years, not associated with wheeze,associated with night time snoring  No C/O chest pain/palpitations/ orthopnea /PND

4. PAST HISTORY: K/C/O HTN since 5 years on T.AMLODIPINE10mg OD K/C/O HYPOTHYROIDISM since 5 years on T. THYRONORM 100mcg OD K/C/O osteoarthritis since 20 years NSAIDS abuse + Not K/C/O T2DM,PTB,BA,CAD,CVD,CKD,CLD,Epilepsy No H/O blood transfusions/surgeries

5.  PERSONAL HISTORY: Takes mixed diet  Bowel and bladder-regular Normal sleep and appetite No addictions  FAMILY HISTORY: NIL significant MENSTRUAL HISTORY Attained menopause 20 years back

6. ON EXAMINATION : Patient conscious coherent oriented GCS-15/15 Pallor - , Icterus - ,cyanosis - ,clubbing - ,lymphadenopathy - ,pedal edema – VITALS: BP- 100/ 60mmhg . BMI- 35kg/m2 PR-92/min RR- 24 /min Temp – afebrile SpO2- 98%@RA  GRBS- 237 mg/dl

7. SYSTEMIC EXAMINATION: CNS:    Bilateral pupils normal in size and reacting to light.               Cranial nerves and HMF, sensory system -normal                Motor system- Bulk- equal on both sides                                          Tone- RT- increased ; LT-normal Power-RT- UL -2/5 LL-0/5 LT -UL-4/5 LL-4/5                                          Reflexes- B    T    S    K    A                                                   RT  +2  +1 +1   +1  +1                                                   LT   +2  +1  +1  +2  +1                                           Plantars - RT- MUTE                                                           LT- flexor

8. CVS:           S1 S2 heard, no added sounds P/A:            Soft, distended, non tender             No organomegaly              Bowel sounds + R/S:              Bilateral normal vesicular breath sounds +             Occasional wheeze +

9. COMPLETE BLOOD PICTURE                   18/10/22                   21/10/22 HEMOGLOBIN                           11.6                      11.2 TWBC                         29.60K                      37.34K NEUTROPHILS                           92                        90 LYMPHOCYTES                           6                        6 EOSINOPHILS                            1                         1 MONOCYTES                            1                         3 PCV                          34.2                        33.8 PLATELET                          80K                        87K TRBC                         3.72mil                        3.63mil MCV                           92                         93 MCH                          31.3                       30.8 MCHC                           34                       33.1 RDW-CV                           16                        17 PERIPHERAL SMEAR Normocytic normochromic anemia,neutrophilic leukocytosis Normocytic, normochromic anemia , neutrophilic leukocytosis

10. RENALFUNCTION TESTS                 18/10/22               20/10/22 SERUM UREA                     129                    213 SERUM CREATININNE                     2.6                    5.0

11. SERUM ELECTROLYTES                   18/10/22                20/10/22               21/10/22 SODIUM               133                     135 POTASSIUM                3.9                     4.9 CHLORIDE                105                     99 CALCIUM                7.3 CORRECTED CALCIUM-                   9.3                                   6.7 PHOSPHOROUS                 7.2

12. ARTERIAL BLOOD GAS ANALYSIS  AT ADMISSION    @Room air         AT 36 hours     @4 LIT O2 pH             7.397              7.360 PO2               92                171.4 pCO2               22.6               20.6 cHCO3-               16.7               15.2 Lactate               3.07                 03.32

13. LIVER FUNCTION TESTS TOTAL BILIRUBIN                               1.4 DIRECT                               1.0 INDIRECT                              0.4 ALP                              262 SGOT                               43 SGPT                              33 TOTAL PROTEIN                              5.4 SERUM ALBUMIN                               2.5 SERUM GLOBULIN                              2.9 A/G RATIO                             0.8:1

14. COMPLETE URINE EXAMINATION MICROSCOPIC EXAMINATION                             18/10/22 RBC 2 WBC                                    2 SQUAMOUS EPITHELIAL CELLS                                   4 BACTERIA NIL CHEMICAL EXAMINATION BILIRUBIN NEGATIVE KETONE BODIES NEGATIVE BLOOD                                    +++ PROTEIN 1+ GLUCOSE NIL NITRITE NEGATIVE LEUKOCYTES                                    +++

15. OTHER INVESTIGATIONS TSH-2.33 HBA1C- 10.4%

16. CT BRAIN CONFLUENT HYPODENSITIES NOTED IN BILATERAL PERIVENTRICULAR AND DEEP WHITE MATTER REGIONS, MORE SO IN FRONTAL REGION DIFFUSE CEREBRAL ATROPHY EVIDENT BY PROMINENT SULCI, CISTERNAL SPACES AND VENTRICULAR SYSYTEM LEFT SPHENOIDAL SINUSITIS NOTED MOVEMENTS ARTEFACTS CANNOT BE DISTINGUISHED FROM INFARCTS AT VARIUOUS REGIONS- ADVISED MRI BRAIN

17. CT pelvis NORMAL VITALS BP-100/70mmHg PR-94/MIN RR- 28 /MIN SPO2-97% ON RA GCS-E4V5M6-15/15 PUPILS B/L 3mm SLUGGISH REACTING TO LIGHT

18. PROVISIONAL DIAGNOSIS CVA- RT HEMIPARESIS, ISCHEMIC SEPSIS DRUG INDUSED PRE RENAL AKI T2DM, HTN, HYPOTHYROIDISM, GRADE 3 OBESITY WITH OBSTRUCTIVE AIR WAY DISEASE

19. TREATMENT GIVEN INJ.CEFOPERAZONE +SULBACTAM 1.5gm IV BD 1-0-1 IVF 2 UNITS  Inj.BASALOG S/C @10PM IJ.H.ACTRAPID S/C TID T.AMLODIPINE 10mg OD 1-0-0 Nebulisation with DUOLIN,FORACORT 8 th hourly 1-1-1 T.THYRONORM 100mcg OD 1-0-0 T.ACEBROPHYLLINE 100mg BD 1-0-1 Strict I/O charting,hourly BP,PR,RR monitoring

20. 19-1--22 PULMONARY MEDICINE CONSULTATION ? OBSTRUCTIVE SLEEP APNEA AdVised BIPAP SOS OPHTHALMOLOGY CONSULTATION Anterior segment normal Patient not cooperative for fundus examination

21. TREATMENT GIVEN INJ.CEFOPERAZONE +SULBACTAM 1.5gm IV BD 1-0-1 IVF 2 UNITS @ 60ml/hr Inj.BASALOG  S/C @10PM IJ.H.ACTRAPID S/C TID T.AMLODIPINE 10mg OD 1-0-0 Nebulisation with DUOLIN,FORACORT 8th hourly 1-1-1 T.THYRONORM 100mcg OD 1-0-0 T.ACEBROPHYLLINE 100mg BD 1-0-1 Strict I/O  charting,hourly  BP,PR,RR monitoring

22. 20-10-22                           TREATMENT GIVEN VITALS BP-120/70mmHg PR-85/MIN RR- 3 8/ MIN SPO2-9 0% ON RA GCS-7/15 PUPILS B/L 3mm SLUGGISH REACTING TO LIGHT PATIENT SHIFTED TO ICU IN VIEW OF DROWSINESS AND DECLINING GCS Inj.LMWH 0.4cc s/c OD INJ.CEFOPERAZONE +SULBACTAM 1.5gm IV BD 1-0-1 Inj . CLINDAMYCINE 600mg IV BD 1-0-1 T.AZITHROMYCIN 500mg OD 1-0-0 IVF 2 U NS, 1U RL @60ml/hr T.ASPIRIN 150mg OD 1-0-0 Inj.BASALOG  S/C @10PM IJ.H.ACTRAPID S/C TID T.AMLODIPINE 10mg OD 1-0-0 Nebulisation with DUOLIN,FORACORT 8th hourly 1-1-1 T.THYRONORM 100mcg OD 1-0-0 T.ACEBROPHYLLINE 100mg BD 1-0-1

23. CARDIOLOGY OPINION IMPRESSION  ECG – normal sinus rhythm T INVESRIONS IN V4 -V5  2D echo – GOOD LV systolic function EF-60%                    No LV RWMA                    Mild TR/PAH RVSP-30mmHg                    Grade 1 diastolic dysfunction                    IVC- normal and collapsing ADVISE: Continue same treatment

24. NEUROLOGY REFERRAL IMPRESSION RT HEMIPARESIS ? VASCULAR METABOLIC ENCEPHALOPATHY ADVISE: 1) T. ASPIRIN 150mg OD 0-1-0 2)T.ATORVOSTATIN 40mg OD 0-0-1 Referred i /v/o FLUCTUATING CONSCIOUSNESS

25. AT 4.45PM Patient became tachypnic VITALS BP-60/40mmHg PR-78/MIN RR- 40 /MIN SPO2-95% ON 15 lit o2 CVS-S1 S2 + R/S- B/L AE +    WHEEZE + P/A- Soft, diffuse tenderness present CNS- GCS-14/15    PUPILS B/L NSRL    PLANTARS-B/L MUTE IVF 1 U NS BOLUS GIVEN INJ.NORADRENALINE 3.6ml/ hr

26. 21/10/22  8:00 AM patients pulse was feeble and BP was 70/40mmhg,     spo2-85% on 15 ltrs o2,    immediately fluid bolus was given followed by Inj.NORADRENALINE drip 18.5ml/hr 8.05AM BP- not recordable on Inj.NORADRENALINE Pupils – mid dilated ,sluggish reacting to light Inj.DOBUTAMINE was started with 10mcg/hr

27. Immediately high quality CPR was started along with  Inj.NORADRENALINE 1cc    BP – not recordable    Pulse – not felt   SpO2 – not recordable CPR was continued for 30 in along with Inj.NORADRENALINE in between cycles of CPR.Inspite of above resuscitative measures,patient couldnot be revived and was declared dead at 8:30AM on 21/10/22

28. FINAL DIAGNOSIS ASPIRATION PNEUMONIA WITH CVA ISCHEMIC STROKE( RT HEMIPARESIS) SEPSIS GRADE 3 OBESITY, OBSTRUCTIVE AIRWAY DISEASE HYPOTHYROIDISM,HYPERTENSION UNCONTROLLED T2 DIABETES MELLITUS