DISCHARGE SUMMARY - CASE ANALYSIS
Department & Admission:
Patient admitted to department: Internal Medicine Service
Admission: 12/06/2025 - Discharge: 13/06/2025, Length of stay: one day
Epicrisis:
Exitus letalis occurred on 13.06.2025 at 21h 23 minutes.
Patient hospitalized on 12.6.2025 to our department due to poor general condition. Patient is a resident of Golden Age home, brought by ambulance accompanied by medical nurse, who provides heteroanamnestic data that patient was poor, not communicating, swollen, had difficulty breathing, coughing with expectoration of whitish content. His head is constantly lowered. Disoriented from before. Saturation at home was 62%, pressure 60/40 mmHg. Urination and stool normal.
From medical documentation previously known chronic atrial fibrillation heart failure, mitral and tricuspid insufficiency, chronic kidney weakness chronic anemia and psychoorganic syndrome.
Objective Findings:
Objectively on admission conscious, disoriented, poorly communicative, at rest eupneic, afebrile, examined in lying trolley. Auscultatorily on lungs audible rales. Heart action arrhythmic, tones clear, murmur not heard. Abdomen without tenderness. No peripheral edema. BP: 90/60 mmHg
Laboratory Findings:
In performed lab findings azotemia anemia, hyperkalemia, high values of liver function tests.
Hospitalization Course:
Placed in coronary unit where with monitor follow-up prescribed infusion solutions with loop diuretic, PPI, cardiotonic, class III antiarrhythmic, cephalosporin antibiotic, corticosteroid therapy, bronchodilators with other comorbidity therapy. On the second day of hospitalization patient had abundant melena, surgeon and intensivist consulted. Included transfusion of depleted RBC and FFP of appropriate blood group, Vitamin K, metronidazole. Despite application of mentioned therapy no improvement of condition, so on 13.06.2025 at 21h 23 minutes exitus letalis was determined.
Transfusions:
During hospitalization prescribed 1 dose of deplasmatized RBC "O" RhD+ blood group in dose 360 ml and 1 dose FFP "O" RhD+ blood group in dose 200 ml.
