An untimely death

This was a case that I encountered on our last day of posting.

Mr.MH is a 72 year old man who is known to suffer from a right colon ca diagnosed in 2007. He had an anterior resection done with a formation of an ileostomy at that time. He also suffers from hypertension and diabetes mellitus for the past 6 years and was diagnosed with chronic renal failure last year which was attributed to these co-morbidities.

He presented currently with symptoms and signs suggestive of acute pyelonephritis for 3 days prior to admission. Examination revealed renal angle tenderness as well.

Renal profile showed severe renal impairment with hyperkalemia. Ultrasound revealed a picture of bilateral obstructive uropathy. A CT Urogram was planned.

He was only managed with a Dextrose Insulin and Potassium regime to correct his hyperkalemia. No ANTIBIOTICS were prescribed.

On the third day of admission, he deteriorated and past away.

Issues that I faced :

1. The CT urogram was suggested on the first day of his admission and the patient did not agree to it. However it took almost 2 days for the doctors to get a consent. I managed to witness one of the attempted consent. In my opinion, that attempt underlines the fundamental of medicine that is COMMUNICATION. The patient clearly did not understand what the CT urogram was and what for. The doctor's haphazard explanation of CT Urogram would drive any patient away.

2. He did not record any fever after being admitted. This was the doctor's explanation for not prescribing antibiotics. I feel the doctor failed to recognise that acute pyelonephritis can have varying presentation and non-specific symptoms. Fever is usually present but it may not be all the times. An empirical antibiotic therapy should be initiated pending results of blood/urine cultures.

3. Once the patient stopped breathing and became pulseless on the third day, CPR was initiated. Chest compression was started while intubation was done to secure the airway. All other protocols were followed. However the cardiac monitor showed ventricular fibrillation. The doctor failed to notice this and kept ordering chest compression to be continued. A DEFIBRILLATION needs to be done to shock the heart out of ventricular fibrillation. I feel its a big error on the doctor's part for not picking up the rhythm on the cardiac monitor.

4. While this was going on, another doctor came and ordered to stop resuscitation as he/she obtained a DO NOT RESUSCITATE from his wife during this ordeal.

Now I may not be familiar with letter of the law, but by definition, a DNR is an ADVANCE DIRECTIVE that is to be followed when a person's heart or breathing stops and they are unable to communicate their wishes to refuse treatment that could allow them to die. As rightly pointed out by my colleague, can a DNR be obtained while resuscitation is being performed? I would like an expert opinion on this matter.

I think not. But I may be wrong.

The official cause of death was advanced colon cancer. I do not agree at all at this COD. No CT scan was done previously to confirm a recurrence or metastasis. How can one confirm this as the cause with no evidence? My cause of death would be Acute Renal Failure and Sepsis secondary to Acute Pyelonephritis.

Though the prognosis for this patient was bad to begin with, the eventual outcome did not surprise me with all the mismanagement and haphazard approach of treating this patient. I think being critical of the doctors is important. But equally so, is our approach and competency in knowing what we are executing.

Patient with DKA

Madam PG is a 29 year old young woman with poorly controlled diabetes on oral hypoglycaemic agents for the past 2 years, who also has history of peptic ulcer disease and 2 recent admissions for diabetic ketoacidosis. She presented on the 21^st of March 2011 with nausea and vomiting for 2 days associated with epigastric pain. During this period she was unable to tolerate orally and had not been able to take her medication. She had no symptoms suggestive of a respiratory or urinary tract infection. On admission she was moderately dehydrated and lethargic however she was not in respiratory distress. Her capillary blood glucose reading was 23.6 mmol/L and her vital signs were as follows: BP: 130/80, pulse: 110, temperature: 37.2C, respiratory rate : 20 and SPO2: 100% on room air. Her venous blood gases showed metabolic acidosis, her serum ketone level was 5.8 mmol/L and ketones were also detected in her urine. She was also noted to have a thyroid enlargement however she was clinically euthyroid. In the ward, she was treated with an intravenous insulin infusion, initiated at 6 units per hour (0.1units/kg/hour), and rehydrating fluids both of which were adjusted according to her blood glucose level. Potassium supplementation (1g/hr of KCL in each alternate bottle of fluid) was commenced on day 2 of admission when her K⁺ levels dropped from 4.5 mmol/L to 3.6 mmol/L. On day 5 of admission her general condition improved and she was no longer acidotic (VBG: no acidosis, serum ketones: 0). She was started on of s/c actrapid insulin in place of IV insulin and was discharged well on the 27^th of March 2011 with s/c mixtard insulin and T. Metformin.

Issues in this case

From her diagnosis 2 years ago, Madam PG has been labeled as a type 2 diabetic. However, because of her young age, frequent episodes of DKA, poor diabetic control with OHAs as well as the associated clinical finding of a goiter, could Madam PG be a Type 1 diabetic instead? During clerking, it was also revealed that her mother was also diagnosed with type 2 diabetes at a relatively young age (in her early 30s), another fact in favour of type 1 DM. In the ward, the managing doctors considered ordering a C-Peptide measurement for her. However, it was not done as the rationale was that, whether she has type 1 or type 2 diabetes will not change the subsequent management because she will be started on insulin following this admission. Should more have been done for her in terms of diagnosis of type 1 DM? Would an autoimmune screen be necessary as she also has a thyroid enlargement?

Supply vs demand??

Hi there, just to share my case.

Patient, Madam SA, a 44 year old Malay lady was admitted on 15^th of March for cramping over both upper limbs, lower limbs and neck.

It was due to hypocalcaemia that she has been having since 3 years ago. Patient was put on long term calcium supplement after a thyroidectomy in year 2008. She claimed that since the operation, she had frequent cramps and was told that she developed hypocalcaemia as a complication of that surgery and needed life-long calcium supplement and to hospital for monthly calcium Injection.

However, things did not go well as very often, the hospital claimed that they ran out of stock. Even with calcium supplement patient was still having cramps very often and with inadequate supply, her condition got worse. She claimed that she has hoarseness of voice as a result of the operation as well also. She has one son studying KL and seldom visits her as he is busy with his studies. Her husband passed away 10 years ago in an accident. She currently stays alone and had stopped working since her thyroidectomy 3 years ago.

She said that she was feeling very sad and hopeless because all she wanted at that time when she went for the surgery was to be euthyroid but she ended up having all these complications instead. She regretted going for the surgery and has depressive symptoms because of that.

Lets focus on her problems. Firstly, the operation itself. She came in for what she came was hyperthyroidism and ended up having hoarseness of voice and frequent cramps as a result.

She was put on calcium supplements but in the end, the supply ran out not once, but continuously. She also developed depression in the end.

From a high hope of actually treating her hyperthroidism, she ended up with cramps every now and then, hoarseness of voice and also depression.

The least we can do now is to try to find a way to help her on getting an uninterrupted supply of medication.

Any comments?? Ways to ensure she gets her medication?

In my opinion, we can try talking to the pharmacist, try to work this out. Buying from pharmacies by herself is difficult due top her financial constraint. Maybe hospital buy for her or maybe getting emergency supply from other hospitals?

Haematuria

Mr. J, a 45 year old man with Diabetes Mellitus, Hypertension, Congestive Cardiac Failure and Atrial Fibrillation has had multiple admissions to the ward, presenting with scrotal oedema, ascites, bilateral leg swelling and sacral oedema. During this admission, his main complaint was scrotal oedema and pain in the groin area. He's on statins among other medications and had a urinary catheter inserted for input-output charting.
Among the many other problems of his, he developed frank haematuria on the 2nd day of admission. He told the house officer but the medical team didn't seem to be bothered by it. The haematuria didn't stop and accumulated to about 200mls. This was his first episode of haematuria.
This could have been a few of many things, among which trauma from CBD insertion (although perhaps unlikely as he continued to bleed for a whole day), possibly from paraphymosis as he was also complaining of penile pain.
So, I decided to bring this to the attention of the doctor in charge as if the blood clots, this could lead to urinary obstruction resulting in further complications. However, the doctors dismissed it as statin myositis. Upon looking up his investigations that were done on admission (the day before), I found raised CK (3x upper limit), LDH and AST (both raised 2x upper limit), which could be in keeping with myositis. But from the simple knowledge that I have, I understand that even if it were truly statin myositis, it should not be dismissed as it could be fatal in some patients and that the statin should be withdrawn.
In my opinion, this case raises important issues surrounding professionalism and ethics as well as mismanagement and patient safety. What was further upsetting was that despite Mr. J having haematuria and complaining of groin pain, no one had examined the groin area. How could we have made a difference in the management of this Mr. J?

Treatment with Anticoagulants

I met Mr. MK, a 63 year old Malay gentleman, on the 14th of March 2011 in Ward 3. He came in for chest pains characteristic of ischaemic origin. He has no known medical illnesses but smokes daily (a total of 32 pack years). A diagnosis of Acute Coronary Syndrome was made and after relevant investigations, it was revealed that he had experienced an anterolateral Non- ST Elevation Myocardial Infarction.

Along with aspirin, sublingual glyceryl trinitrate (GTN) and oxygen therapy, a stat dose of fondaparinux was givin in the Accident & Emergency Department. His pain was relieved.

In the ward, he was treated with aspirin, simvastatin, isosorbide dinitrate, enalapril and metoprolol with sublingual GTN to use when necessary. Fondaparinux was replaced with clexane on the 2nd day of admission.

He developed no complications during his stay and serial ECG taking showed no further ischaemia. He was discharged on the 4th day of admission, to be reviewed in a month's time. Medications prescribed were aspirin, simvastatin, isosorbide dinitrate, enalapril, metoprolol and sublingual GTN. He was also referred for an echocardiogram.

Queries:

1. Why was fondaparinux replaced with clexane? I have observed that this is done quite regularly in the medical ward. If cost is the reason fondaparinux was replaced with clexane, why begin with fondaparinux initially?

2. Can these two anticoagulants be used interchangeably?

Expert Opinion Wanted !

Hello Hello, this is a case summary involving

Mdm. SH a 24year old Malay girl who is a known case of Chronic Idiopathic Thrombocytopenic Purpura (ITP) since childhood who currently presents with history of a 2 day high grade fever associated with coryzal symptoms, and an productive cough with whitish clear sputum. She experienced 3 episodes of gum bleeding, 1 episode of epixtaxis and had developed a rash over her limbs and torso within these 2 days. She had 2 similar presentation in January this year and October last year. Those times she was treated with a diagnosis of acute on chronic ITP, and was given T. Prednisolone 40mg BD in October and did not receive medications on discharge during her October stay. She has no history of prior transfusion, traditional medications, history of sick contact or travel, history of menstrual irregularities, or history of abdominal pain. She also denied history of anemia, muscle pain, joint swelling, or any retro-orbital pain. She also has had no dietary changes.

On Examination her vital signs revealed a temperature of 40 degrees Celsius, blood pressure of 120/80mmHg, Pulse rate of 74bpm regular, symmetrical and good volume. She appeared to be conscious, alert, and communicative. She looked ill (septic), was not cushingoid and had petichae's over all four limbs, echymosis of the hard palate. There was no muscle haematoma, haemarthroses, anemia, stigmata of chronic liver disease, telangectasia, or palpable lymph nodes. All systemic examinations were normal except reduced air entry over the right lung with ronchi predominantly on the lower lobe of the right lung.

Investigations done revealed
FBC - Hb - 11.4 g/dL, WCC - 6.6x10^9?L, Plt - 18 X10^9/L
BUSE - Urea - 2.9mmol/L, Sodium - 138mmol/L, Pottasium - 3.3mmol/L , Creatnine - 54mmol/L
CRP - 36.7mg/L
UFEME - Ketone 5+, Ereythrocyte 50, Red Blood Cells - 3-4hpf, Epithelial Cells - 1-2hpf

She was then treated with a diagnosis of Acute on Chronic ITP, there were no measures taken to culture or investigate her underlying infection, no Chest X-ray was done to look for lung disease, no Dengue immunoglobulin markers were taken, a Live function test was not done,
She was given,

• IV Platlet 4U together with IV Methylprednisolone 500mg OD x 3/7
• T. Prednisolone 60mg BD discharged with a monthly reduction of 5mg
• T. Calcium Lactate 600mg ON
• T. Paracetamol 1g QID
• T. Ranitidine 300mg OD
• T. Omeprazole 20mg OD
• IV Fluids maintainence at 4pints over 24hours

Her Platelet count post transfusion was 28, and she was allowed to be discharged after a 3 day still febrile with 38 degrees Celsius, still having a cough, still having the petichae's. If the patient were to ask "Whats wrong with me?" , "Why am I always getting sick in these past few months?",  "Am I ok?"...... How will you answer, and what would be your approach to this patient if she happens to get admitted during your call? 

Patient With No Known Contacts

I saw this patient few weeks back :

This is a male patient 76 years old that was admitted presented with lethargy and generalised body weakness with fever. History from this patient is vague as there was no relatives around and patient could not talk. Besides that, he has been staying alone also. He was found lying in the house by his friends that comes over for visit and notice that he's having fever and was then brought to the hospital. Throughout the stay and further investigation, community acquired pneumonia was diagnosed for this patient. Besides that, it was found out that patient is actually a known case of lung carcinoma on chemo and radiotherapy. However, we do not know wether patient has completed his treatment or not. Throughout the stay in hospital, there were no visitors and contact tracing was unsuccessful. He was only being managed as community acquired pneumonia and optimized his nutrition state. Patient eventually passed away suddenly in the morning.

If you were the doctor, besides treating the pneumonia and his nutrition state, would you have done different?

If contact tracing is still unsuccessful what else can we do after we treated his pneumonia?

I would treat his pneumonia and try to investigate regarding his lung carcinoma to make sure has he completed his treatment or not or what was the plan of management for his lung carcinoma. After that what will you do?Discharge him and let him goes back to his house alone without people taking care?Palliative Care?

Post-Stroke Blood Pressure Control

My patient, a 63 year-old Malay gentleman with underlying hypertension and hyperlipidaemia, presented with sudden onset of left-sided body weakness. Physical examination showed signs of upper motor neuron lesion, such as hypertonia, muscle power 1/5, hyperreflexia, positive ankle clonus and positive Babinski sign. CT brain scan confirmed the diagnosis of acute ischaemic stroke as it showed infarction at right frontal lobe with underlying cerebral atrophy.

Diagnosis: Acute Ischaemic Stroke with left-sided hemiparesis, with underlying hypertension and hyperlipidaemia

During admission, his blood pressure was 148/80mmHg. The patient was given tablet Amlodipine 5mg OD on the first day but withheld on the second day on the second day of admission.

Blood Pressure Control
In poor flow state as occurs with thrombotic ischaemic stroke, the cerebral vasculature is without vasoregulatory capability and thus relies directly on mean arterial pressure (MAP) to maintain cerebral blood flow. Therefore, aggressive efforts to lower blood pressure may decrease perfusion pressure and may worsen ischaemia.

I think this patient should not be given Amlodipine as his blood pressure was not high during admission. Antihypertensive agent may worsen cerebral ischaemia in acute ischaemic stroke.
Therefore, antihypertensive agent should only be given 2 weeks after the event.

What would the appropriate blood pressure control in this case?

Short Case

This patient was seen a few weeks ago back in the ward.

A lady, 43 years old, known case of previously diagnosed and treated abdominal sepsis presented to the ward with presentation of acute abdomen with fever.She was also a known case of end stage renal failure on maintenance dialysis via IJC and Diabetes Mellitus for 8 years. This time upon presentation, the first line of doctors who saw her just gave her Tablet Paracetamol for the fever which was spiking ( around 40 degree Celsius) on PRN basis.

This continued for duration of 1 day throughout her admission and when she was reviewed the next day, the medical officer then realized that she was not given any antibiotics. She was then started on IV Augmentin.

Note : When a patient comes in with high fever and abdominal pain, we have to always rule out abdominal sepsis before anything else because if not treated early the patients can go into shock and fatality is high. Hence early administration of antibiotics is needed. Adding on, the medical officer also told that if at any point as a house officer we are not sure about the management or hesitant to start with any medication, we should always consult the medical officer on call. This is important in ensuring all our patients get the best treatment from the health care staff.

Shelva Meena

Short case

49 year-old man diagnosed having HIV 10 years ago. He was not on any anti-retroviral drug or HAART regime. He was an IVDU, stopped one month ago. He presented with left sided chest pain associated with mild shortness of breath and palpitation on the day of admission. He also complained of passing watery loose stool and left lower quadrant abdominal pain 2 days prior to admission. The stool was yellowish in colour, no blood and no mucus. He vomited once on the day of admissionhad but had no fever.
On physical examination, he was cachexic looking. His hydration status was good. His apex beat was deviated. There was grade 2 diastolic mumur heard over the left lower sternal border and collapsing pulse was presence. however, he had no stigmata of infective endocarditis. There was tenderness over left lumbar and left iliac fossa. however, the abdomen was soft, no guarding and no hepatosplenomegaly.
His ECG showed left ventricular hypertrophy, T wave inversion at V1-6. Troponin-T and non specific cardiac enzymes were not elevated at the time of presentation. His FBC and renal profile were normal. Chest X-ray showed cardiomegaly and no other changes.
The other test results were not back.

He was treated as acute coronary syndrome and acute gastroenteritis (HIV related). He was also reffered to optalmologist for checking CMV retinitis.

On the next day, he requested to discharge. His chest pain resolved but still have minimal abdominal pain and diarrhoea. The doctor allowed him to discharge.

DO YOU AGREE WITH THE DOCTOR DECISION?

Case 3

This is a patient I saw last week in the male ward.

Mr A, a 60-year-old Chinese man, previously diagnosed with nasopharyngeal carcinoma 10 years ago and currently in remission for 5 years now, was admitted for chronic cough for 5 years. The cough started insidiously 5 years ago and at that time the sputum was greenish-whitish in colour. However, 2 years ago, he started having hemoptysis as well. The sputum coughed up now is thick blood mixed with mucus and about half cup to one cup each time. He also complains of intermittent low grade fever for the past 2 years and night sweats as well. He also has dizziness and headache after a bout of hemoptysis. However, he does not have any palpitations or fainting spells. He contracted nasopharyngeal cancer 10 years ago as he was working in a glue factory then. He had a growth in left nostril and completed radio and chemotherapy for it. He was told that his cancer was cured after completing therapy. He is under follow-up at Hospital Melaka for it. He currently has anosmia, reduced hearing but his sense of taste is still present. He does not have any TB contact and no other person staying with him has any similar signs and symptoms. He stays with his wife and his sister now. He is fully dependant on his wife and sister for income and housing as he lost his job at the glue factory as the factory closed down.

On examination, Mr A is alert, comfortable and cooperative. He cannot lie supine on his bed as he claims it will irritate his throat and cause him to cough. There is clubbing over all his fingers and toes. Capillary refill time is less than 2 seconds. However, he has pallor over his hands and conjunctiva. He does not have any jaundice. There is no signs of Horner's syndrome. Trachea was not deviated. On examination of his lungs, there is equal chest expansion of both lung fields. On tactile fremitus, there was increased resonance over the right middle and lower lobes of the lungs. On percussion, there was dullness over the right middle and lower lobes. On auscultation, there were normal vesicular breath sounds heard with no added sounds. On vocal fremitus, there was increased resonance over the right middle and lower lobes of the right lung as well.

Mr A had undergone many chest X-rays and CT scans over the past 5 years. The latest chest X-ray found a dense well-defined nodule in the right lower zone measuring about 3.5x2.5cm. CT scan in 2007 found consolidation of the right middle and lower lobe. Small bullae were seen within consolidation. AFB sputum was done in 2008 for one sample and was negative. ESR was also raised at 77. Full blood count showed hemoglobin 8.8 but other parameters were normal.

From the case, my differential diagnoses would be either a TB infection or a lung carcinoma, either primary or secondary from his previous nasopharyngeal carcinoma. Either way his symptoms are sinister and should not be allowed to drag on further. However, he was only admitted for less than 12 hours. He was treated with antibiotics for pneumonia and discharged with a follow-up visit to the MOPC 2 weeks later. The MO-in-charge thought of the above differential diagnoses but did not bother to take further action to investigate further. The official diagnosis written in the case notes was also pneumonia. The other symptoms were made light of. I feel that it is very unethical to just push the patient off and not bother about what will happen to him when he has already gone through so many prior investigations. Mr A was very desperate for someone to just listen to him and diagnose and treat him properly. Hopefully whoever who will see Mr A in the MOPC will attend to his symptoms properly and treat him as soon as possible.

Yilin

Case 2

63 year old female presents with breathlessness of 7 days prior to admission. The breathlessness started progressively and is increasing in severity prompting her to seek medical attention. Associated with the breathlessness are reduced effort tolerance and general malaise for 2 weeks prior to admission. Further history revealed similar presentations over the past 1 year requiring multiple admissions.

She was diagnosed with atrial septal defect 8 years ago and had a corrective surgery done at that time. She was free of symptoms till one year ago. No co-morbidities.

Examination revealed a cachectic female lying comfortably on the bed. Vitals were normal except for a bradycardic pulse with an irregularly irregular pulse and low BP ( 97/50 )

Cardiac examination revealed multiple valvular heart lesions. There were presence of a Grade 3 pansystolic murmur heard best at the apical region radiating to axilla as well as a pansystolic murmur at the tricuspid region( pulsatile liver was also present). An early diastolic murmur was also heard at the left sternal edge on sitting position and in expiration.

Patient also had signs suggestive of congestive cardiac failure as evidenced by a displaced apex beat, raised JVP, hepatomegaly, bibasal crepitations ,scleral jaundice and pedal oedema. CXR showed cardiomegaly.

ECG tracing revealed atrial fibrillation with right bundle branch block. Liver function test indicated unconjugated hyperbilirubinaemia with evidence of hepatocyte injury. A previous ECHO done last year showed ejection fraction of 55 %.

She was started on IV Frusemide to initiate diuresis. She was also given IV dopamine infusion, T.Spironolactone and put on fluid restriction of 800 cc per day.

Any comments?

Is this management optimal for this patient?

Case 1

This is a case i saw today in the clinic. Therefore the information provided here is not that detail. However the issue that i want to bring it up is regarding ethical issue. Patient is a 63 year old female, known case of diabetes, hypertension, hyperthyroidism, mentally challenged secondary to childhood enchephalitis and also invasive ductal carcinoma of the left breast. Her reason for this clinic follow up is for her antihypertensive and also insulin therapy for hypertension and diabetes. Her hyperthyroidism is being treated with carbimazole. The important issue here is her invasive ductal carcinoma of left breast. The MO that i was tag to explain to the patient and also her son who came along regarding the her carcinoma and the risk of death if there is no treatment undergone. This is because the patient's family member's refuses to do the surgical management for the carcinoma and the patient is not mentally fit to decide for herself. Despite being advise by the surgical department, the family members still refuses to undergone the surgery. What could us as a health professional do in this kind of situation? From what i have gathered and also the opinion i sought from the MO and the specialist in the room, we need to respect patient's autonomy in which in this case patient is not mentally fit to decide for herself which ends up with her next of kin. We need to do our best to advise the family members and persuade them to undergone the surgery in view of her life threatening condition. Even if it fails, at least we have done our job as a doctor. However, there is still one thing in which we could do which are in the legal issue. We go over ride the decision of the family members in view of this kind of condition. It is being done in overseas but in Malaysia context, we are still bounded by social rules in which the family plays an important role despite having the legal method. Therefore, this kind of scenario is very hard to be dealt with. Is there any other ways that we could handle this? Give your thoughts if you do have any opinions in this. :)

-trf-

Test Test

Test test..see if this works..thanx to harkeerat and sundar for creating this blog

start posting guys!:)

-trf-