MORTALITY

Mr. L
DOA : 23/3/2020
DOD : 7/4/2020
Cause of death : SEPTIC SHOCK SECONDARY TO DIVERTICULITIS WITH
UNDERLYING LIVER CIRRHOSIS
Underlying
1/ Liver Cirrhosis
Hep B Hep C HIV NR ( sept 2018)
US Abd : 16.12.2018 - Cirrhosis complicated with splenomegaly and splenic varices in keeping with
portal hypertension
- Child's Pugh B

2/ Bicytopenia likely secondary to chronic liver disease with portal hypertension

- platelet baseline range 66- 97
- TWC range 3-5
3/ Esophageal varices
-OGDS Sept 2018 : Esophageal varices, banded x5.
-AFP (24/3/2020) 3.9

4/ Left inguinal hernia under surgical, plan for op but postponed due to failed cardiac assessment
and thrombocytopenia
5/ Right inguinal hernioplasty 20years ago
 H/o admission to surgical ward treat as colitis (discharge on 17/2/2020)
 -presented with same symptoms
 -done CT Abdomen and Pelvis on 14.2.2020
Findings :
1. Generalized right sided bowel wall thickening, predominantly at the caecum
and ascending colon. Differential include bowel infarct, colitis or malignancy.
2. Liver cirrhosis with portal hypertension.
3. Acalculus cholecystitis.
4. Subcutaneous cystic lesion at the inferior paraumbilical region. Features could
represent epidermal inclusion cyst
23/3/2020 at 02:10H in ED
Presented with :
abdominal pain x3/7 - over the epigastric region radiate to RIF
fever x2/7
vomiting x2/7 - 2-3episode/day, food and fluid content
diarrhea x2/7 - 2-3episode/day, watery stool, no blood
reduce oral intake

otherwise
no SOB / chest pain / UTI symptoms / URTI symptoms

On examination :
alert, pink, not tachypneic, good pulse volume, warm peripheries, CRT < 2sec
Vital Signs :
BP 144/77 mmHg
Temperature 38.8° C
Pulse 114 /min
SPO2 99 %
Pain Score 3/10
lungs: clear
CVS: DRNM
p/a: voluntary guarding over RIF

IMP : acute appendicitis

1st day admission 23/3/2020
s/b consultant during morning round
Abdominal pain same as previous admission – more over right side
Feverish, no vomiting, no diarrhea
On examination alert, conscious
VS stable

P/A tender over RHC

TWC: 8.32
Hb: 12
INR: 2.46
Plt: 31
TB: 50 -direct 17, indirect 33
ALP: 72
ALT: 20
Plan :
to get US abdomen today
monitor LFT
Transfuse 4 unit FFP and 2 unit platelet
start IV cefobid/flagyl
IV tramal 50mg QID
IVD 4pints NS/24
s/b MO during night round
 just completed 4U FFP and 2U platelet
 Still having pain over right hypochondriac

 O/E alert
 VS stable
 P/A soft
 INR 2.46  1.85
 Plt 31  67
 US abdomen 23/3/2020
 Indication: To look for any dilated systems or any calculi in the biliary systems.

Findings:
Liver is heterogenous and coarse in echotexture with irregular margin in keeping with liver cirrhosis. No focal liver parenchymal
lesion. Intrahepatic biliary tree not dilated. Portal vein is normal in calibre and patent.
Gall bladder is distended, no calculi. Visualised CBD is not dilated measuring 0.5cm.
Visualised head and part of body of pancreas appear normal.
Spleen is enlarged measuring 16.4cm. No focal lesion.
Splenic varices seen.
Both kidneys are normal size and echopattern.
Right Kidney - Bipolar length : 10.2 cm , parenchymal thickness : 2.0 cm.
Left Kidney - Bipolar length : 11.5 cm , parenchymal thickness : 1.3 cm.
No focal lesion, calculi or hydronephrosis in both kidneys.
No perinephric collection or suprarenal mass seen bilaterally.
Visualised both psoas muscles appear normal.
Urinary Bladder – underfilled
 Prostate is not enlarged.
Visualised bowel loops are unremarkable. Appendix is not visualised.
Minimal free fluid seen at right paracolic gutter and right iliac fossa region.

Impression :
1. Liver cirrhosis with evidence of portal hypertension (splenomegaly and splenic varices).
2. Minimal free fluid at right paracolic gutter and right iliac fossa region. Suggest clinical correlation.
 Plan
 allow orally
no need to tranfuse more
cont antibiotics
cont Vit K
IVD 4pints NS/24H
LFT cm
2nd day admission 24/3/2020
s/b surgeon during morning round

 O/e alert, conscious

 VS stable
P/A soft
LFT increasing in trend
total bilirubin 50 -> 89
direct increasing 17 -> 22
Indirect 33 -> 67
ALP 72 -> 96
ALT 20 -> 17
amylase 32
TWC 8
IMP: acute hepatitis

Plan :
continue cefobid/ flagyl
KIV CT scan if LFT worsening
LFT monitoring
send for AFP
Refer medical
24/3/2020 medical review in K1
Case D/W physician

Unlikely acute hepatitis

Decompensated cryptogenic liver cirrhosis , likely secondary to recurrent colitis
TRO obstructive jaundice
AKI

Plan
Continue antibiotic
For CECT Abdomen if persistent abdominal pain
Continue surgical plan
KIV for increase IV Lasix and peritoneal tapping if worsening ascites / SOB
Cont IV VItamin K 10mg X 3/7
Watchout for bleeding tendency and variceal bleeding
3rd day admission 25/03/2020 - 03:36H
Informed by SN patient develop SOB.
noted patient having SOB and unresponsive to call. GCS upon attending was at E2V2M4.

Vital signs
BP 152/80
P 100
T 40
DXT 5.5

Lungs: Minimal rhonchi

CVS: DRNM
P/A: soft, distended
 Plan :
Run 1 pint HM fast, another 1 pint HM over 1 hours
Repeat baseline + ammonia
Insert CBD
Monitor U/O
For tepid sponging
To take septic workout
3rd day admission 25/03/2020
s/b surgeon during morning round
 REV IMP: Treat as ascending cholangitis
 currently:
 having temperature spike
still having abdominal pain
no vomiting
no diarrhea

o/e:
alert, pink, not tachypnic

BP : 113/ 65
P : 86
T : 37.5
SPO2: 96%
 P/A: soft
lungs: bibasal crepts with reduce air entry
 Plan :
to get CT ABDOMEN PELVIS (granted cm 26/3/2020)
KNBM
IVD 4pint/24H

IV Cefobid/flagyl D3
IV Tramal 50mg QID
IV Vitamin K 10mg OD
syr lactulose 15ml BD
4th day admission 26/3/2020
s/b surgeon during morning round
 No more abdominal pain
 Shortness of breath improving
 No fever

O/e
not tachypneic

BP 153/87
P 113
T 37
SpO2 96% on NPO2

Lungs bibasal crepts

P/A soft
 Plan :
 for CT AP today as planned
IVD 3pint NS/24H with 1g KCL in each pint
IV lasix 20mg BD
continue hourly urine output monitoring
 26/03/2020
12:15 Emergency CT Abdomen Abnormal CECT Abdomen and Pelvis done on 26.3.2020.
Comparison made with previous ct dated 14.2.2020

Indication :
64 y/o u/l Liver cirrhosis with portal HTN / esophageal varices, presented with abdominal pain for the past 1 week localized at periumbilical
region. Treated as colitis. Unsettling temperature. TRO liver/gallbladder abscess/empyema in view of persistent temp spike with ascending
cholangitis.

Findings :
Previously seen bowel thickening and edema seen from caecum until hepatic flexure region is still seen. It causing narrowing of the bowel
lumen however still patent. Worsening of the surrounding fat streakiness noted. There is now free fluid and marked mesentery fat
streakiness seen at the right abdomen. This is associated with abdominal wall streakiness.
No focal enhancing collection seen.
Multiple enlarged mesentery nodes seen, largest measures 1.5cm.
Minimal free fluid seen at left perisplenic and left lumbar region.
The rest of the bowel are normal. Appendix is not identify.

The liver is smaller in size. The liver is coarse in echotexture with irregular surface margin. No focal liver lesion. No dilated biliary tree. The
portal vein is patent, measures 1.1cm.
Gallbladder is normal. No calculi seen within.
Spleen is enlarged measuring 15.3 cm in span. There are multiple splenic varices noted.
Pancreas and both adrenals are normal.

Both kidneys demonstrate normal enhancement. No hydronephrosis seen.

Urinary bladder is underfilled.
Prostate is not enlarged.
Fluid within left scrotal sac suggestive of hydrocele.
Collapse consolidation of right lower lobe.
Degenerative disease of the spine. No suspicious bone lesion.
There is well defined subcutaneous cystic lesion seen at the inferior paraumbilical region as seen in previous study. No intraabdominal extension.
 Impression:
1. Generalized right sided bowel wall thickening with worsening mesentery
streakiness and enlarged mesentery nodes. Infective colitis need to consider.
Suggest clinical and colonoscope correlation.
2. Liver cirrhosis with splenomegaly.
3. Unchanged inferior paraumbilical subcutaneous lesion.
4. No evidence of liver abscess.
5. Left hydrocele
26/3/2020
s/b surgeon during afternoon round

Revised IMP: Treat as infective colitis TWC 12.2

No more shortness of breath LFT
No fever
ALT 13
ALP 123
No chest pain
Total Bilirubin 93
O/e Indirect 61
E3V5M5 Direct 32
not tachypneic

BP 153/87
P 113
T 37
SpO2 96% on NPO2

Lungs bibasal crepts

P/A soft
Plan
To take stool culture, ova and cyst, FEME
Allow orally
Continue IVD 3 pints with 1g KCL in each pint
Continue antibiotics
RP LFT cm
continue NpO
send melioidosis, leptospirosis
continue IV lasix 20mg BD
26/3/2020
s/b surgeon during night round
noted patient restless since this evening REVISED IMP:
having diarrhea 1)treat as diverticulitis
no fever 2)acute pulmonary oedema
 
O/e E3V5M5, not tachypneic  

BP 153/87
P 113
T 37
SpO2 96% on NPO2

Lungs rhonchi, bibasal crepts

P/A soft
pitting edema over bilateral LL

ECG STAT: no dynamic changes

Plan
Allow orally
Start IV lasix 40mg bd
insert CVL
continue antibiotic
off IV drip
neb combivent 4hly
Continue I/O charting
Send D dimer, ABG, ammonia
repeat ABG 1H post neb and reassess patient
KIV to refer anesth for NIV
 5th day admission 27/3/2020
s/b surgeon during morning round
IMP: Plan
1)Treat as diverticulitis For physician to review
- conservative Hourly urine output
2) Acute pulmonary oedema Cont CVP reading
3) Child pugh C decompensated liver cirrhosis with Continue antibiotics
Grade II hepatic encephalopathy Start Mixt KCL 15ml TDS for 3 days
Cont 4 hourly Neb
Cont lasix
Currently
No fever
No SOB/Chest pain
No abdominal pain
CVL inserted yesterday
No tachypneic
  
Medical review in K1
referred medical for hepatic encephalopathy

history from wife

altered behaviour for the past 2 days
no fever
no vomitting
BO 3x yesterday

prior admission able to feed himself

speaking coherently
IMP :
 1) Altered sensorium for IX -tro CVA /ICB
Ddx hepatic encephalopathy

2) HAI
- developed fever on D3 admission
blood culture 25/3/20 : NG day 2
urine culture 25/3/20 : NG
CXR poor inspiratory film
on IV Cefobid/ Flagyl D5

 Plan
 for CT brain urgent -recent altered behaviour
KIV to take over after review CT brain
Medical review in K1
 review CT brain : no obvious ICB seen
 case updated to physician oncall
 IMP : decompensated liver cirrhosis with hepatic encephalopathy secondary to
diverticulitis

Plan :
monitor DXT qid
syr lactulose 15 mls TDS
to ensure BO at least 2-3 times per day
cont T spironolactone
daily medical review
6th day admission 28/3/2020
Medical review in k1
 no fever past 24 hours
BO x 4 today
 O/E confused , E3V3M5
not tacypniec

BP: 150/ 77
PR: 94
T: 37
SPO: 95%
 DXT: 8.0

lungs: clear anteriorly
PA: soft
  
 IMP : hepatic encephalopathy underlying liver cirrhosis
cover for SBP
 Plan
 medical take over
trace formal CT brain
to cover for SBP - start IV cefotaxime 2g tds , off cefobid and flagyl
repeat blood cultures prior to antibiotic
KIV to fast correct K after review RP repeated
off slow K first - kiv restart back after review repeated RP
withold lasix first
start IVD 1 pint DS/ 24hours
DXT QID

syrup lactulose 15ml bd
IV pantoprazole 40mg od
T spironolactone 25mg bd
T Propranolol 20mg BD
IV cefotaxime 2g tds
Mixt KCl 15ml TDS
Date of admission in K7:
28/3/2020 - 3/4/2020
Under Medical
1) Cover for SBP
- Presented with fever diarrhea vomiting 2 days
- Wcc High
- on IV cefotaxime D1
- Blood culture (28/3/2020): pending
- Bedside US by physician no gross ascites

2) Hepatic encephalopathy precipitated by 1

- serum ammonia 119 (26/3/2020)

--DIL/DNR issued by medical team 30/3/2020--

Able to BO
No fever
No abdominal pain
Passing flatus

Noted per abdomen distended on 29/4/20

PR: Brownish, no mass

Abdomen x-ray - stomach and small bowel dilated

Plan
Do AXR
KIV to refer surgical back
9th day admission 31/3/2020
surgical review in k7 by MO
Refer back to surgical for intestinal obstruction in view of dilated bowel

Currently
Able to BO
No fever
No abdominal pain
Passing flatus

p/a soft, distended

PR Brownish
Abdomen x-ray - small bowel dilated

IMP : Treat as ileus

Plan :
KNBM
For Stomach decompression-Insert ryles tube, keep free flow, aspirate 4 hourly
To correct electrolyte
AXR cm
Surgical review cm
 10th day admission 1/4/2020
surgical review in k7 by MO
current issue: Ileus (AXR 31/3/2020; dilated stomach and small bowel)
 current
no fever
passing flatus
BO yesterday
no vomiting

o/e
alert, not tachypniec

VS stable

P/A; distended
 BS: sluggish

AG : 115cm today
 PR: brownish, no impacted stool

RTFF: 100cc clear today

 AXR 1/4: dilated large bowel

 Plan
allow nourishing fluid
to spigot Ryle's tube
watchout for vomiting
inform back if patient having I/O symptoms
11th day admission 2/4/2020
surgical review in k7 by MO
Issue :
1/ Ileus
-AXR 31/3 and 1/4 Dilated stomach and small bowel
-RTFF on 31/3, spigoted 1/4

Currently
Tolerating NF per oral
No vomiting
Passing flatus
BO x2
Not complaining of abdominal pain
Complaining of bloatedness

O/e
Alert, Conscious
Not tachypneic on RA
VS stable
 AG : 115 --> 112
P/s : Soft, distended - moderate ascites.
Left reducible inguinoscrotal hernia, non tender

BS Active
DRE - Brownish stool, not impacted stool
 Plan
Continue NF
Repeat AXR cm
Surgical review cm
Antibiotics as per medical
Inform if evidence of intestinal obstruction - vomiting, not passing motion or
flatus, severe abdominal pain
Continue pantoprazole OD
12th day admission 3/4/2020
surgical review in k7 by surgeon

Currently
No vomiting
Passing flatus
Able to BO
Not complaining of abdominal pain
Complaining of bloatedness
O/e
Alert, Conscious
Not tachypneic on RA

VS stable

P/a : Soft ,distended

 Abdomen xray :dilated bowel

 IMP: Intestinal Obstruction secondary to SBP /diverticulitis

 Plan
Surgical take over
KNBM IV drip 3 pint NS
Start IV Tazocin 4.5 g QID
Ravin enema BD dose
Ryles tube free flow -Stomach Decompression
13th day admission 4/4/2020
transfer in to k1 , s/b surgeon in K1
IMP: Intestinal Obstruction secondary to SBP /diverticulitis
Currently
No vomiting
Passing flatus
Able to BO x2 today
Not complaining of abdominal pain
Complaining of bloatedness

O/e
Alert, Conscious
Not tachypneic on RA

BP 138/80
P 80
T 37
SPO2 97% RA

P/a Soft ,distended

 Plan
 For NBM with IV drip 4 pints
Continue RTFF
Continue antibiotics
Keep CBD with I/O charting
14th day admission 5/4/2020
s/b surgeon during morning round

 REVISED IMP:
right sided caecal diverticulitis Hinchey 1 with SBP (can be infective colitis)
left reducible inguinoscrotal hernia

O/e Alert, conscious

Not tachypneic

BP 112/66
P 73
T 37
SPO2 95% RA

P/a distended but soft, no peritonitis, no tenderness over RIF

reducible inguinoscrotal hernia

AXR : prominent bowel

Plan
send CEA
change to IVD 2pint HS/24H
for conservative management
off spironolactone
IV lasix 20mg OD
IV Vitamin K 10mg OD
send stool for Clostridium difficile
inform family for conservative mx
15th day admission 6/4/2020
s/b surgeon during morning round
No vomiting
Passing flatus
Able to BO
Not complaining of abdominal pain

 O/E alert, conscious

 VS stable

 P/A soft, distended

 Plan
 Keep RT
Continue syrup lactulose
start enteral feeding 50cc / 3 hourly
6/4/2020
s/b MO during night round

having 1 episode of hypotension 83/39 mmHg

1 pint HM run
BP pickup to 103/75
no fever

BP 103/75
P 73
T 37
SPO2 95% RA
P/A distended but soft, no peritonitis
 Plan
 To monitor BP
continue antibiotics
continue feedings
16th day admission 7/4/2020 at 03:19H
s/b MO
 Informed by SN patient asystole

Attended STAT
Noted cardiac monitor asystole
BP, PR, SpO2 unrecordable
No spontaneous breathing
No pulse palpable
Heart and breath sound not auscultable
Pupils fixed 4mm dilated bilaterally

Upon attending, PAP (wife) refused for CPR

Death pronounced to PAP, accepted. No further question asked.

Cause of death: Septic shock secondary to diverticulitis with underlying liver cirrhosis
Time of death: 03:19H