Case 13
Sudden death
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Brief History
The patient was an elderly Caucasian male with hypertension, insulin-dependent diabetes mellitus with history of diabetic comas and neuropathy, status post coronary artery bypass graft (CABG) surgery approximately 5 years prior, inability to walk, and multiple admissions to hospitals and rehabilitation centers over the past year for a variety of problems including dehydration, elevated ammonia, weight loss, congestive heart failure, food poisoning, pacemaker-defibrillator placement, deep right hip infection with MRSA, and increasing ascites.
The patient was in rehabilitation where he was found on the floor after an unwitnessed fall.
There was concern for bruising.
He died later that day.
The history is obtained from the family.
Discussion Questions
1. Summarize the history.
2. How would you characterize the severity of the patient’s diabetes?
3. What are the main, underlying medical problems of the patient?
4. Why might this patient have an elevated ammonia? What other part(s) of the history might support your answer?
5. What could cause a fall, such as this patient had?
6. When a patient dies after a fall, what might explain this?
7. What concerns might families have about an unwitnessed fall in a rehab setting?
8. What constitutes “appropriate monitoring” in a nursing home? In rehab? On a general medical floor? In the ICU?
9. How is trust built between providers and patients/families?
10. The family was concerned about bruising after the fall. In the setting of an unwitnessed fall, one family might attribute bruising to the fall. Another family might suspect foul play. How would you account for this difference in views? What can you do, as a provider, to build trust with a family?