Case 3 Death Summary

Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
Patient Name: Putul Barua
Patient ID: 135799
Room #: CCU-4
Date of Admission: 01/07/2015
Date of Death: 01/15/2015 at 0041 hours
Admitting Physician: Simon Williams, MD, Pulmonology
Consultants: J. K. McClain, MD, Cardiology; Trevor Jordan, MD, Nephrology
This 42-year-old gentleman was admitted on January 7, 2015 and expired on January 15, 2015. He was
admitted with progressive tachycardia, hemoptysis, and dyspnea. Please see his admission history and physical
exam for details.
HOSPITAL COURSE: The patient’s hospital course was characterized by a progressively downhill course. He
was initially hospitalized and found to be mildly hypoxic, which rapidly corrected with supplemental low-flow
oxygen therapy; however, he gradually became more oxygen dependent on high-flow oxygen, eventually
requiring intubation with mechanical ventilation in order to maintain his oxygenation. He underwent an openlung biopsy in an attempt to delineate the etiology of his pulmonary situation, and this was reported as
idiopathic pulmonary fibrosis and alveolitis. The specimen was sent to the Forrest General Pathology
Department for further evaluation, and they were able to give no further help concerning the etiology of his
pulmonary status. An echocardiogram showed left ventricular wall motion hypokinesia and an ejection fraction
of approximately 35%.
Dr. J. K. McClain and other members of the cardiology department consulted on the patient. They felt that his
hypoxia and breathlessness were not secondary to his cardiac status. He had supraventricular cardiac
arrhythmias, including atrial fibrillation and atrial flutter. The cardiology staff utilized intravenous medications
that controlled the cardiac rate, adequately resolving these cardiac issues. I managed the patient’s ventilator and
intensive care status along with my respiratory therapy team. Unfortunately the patient developed multiple
Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
Patient Name: Putul Barua
Patient ID: 135799
Room #: CCU-4
Date of Death: 01/15/2015
Page 2
infections, hospital acquired, including Klebsiella pneumoniae infection and probable fungemia. Multiple
evaluations of the sputum and lungs for the presence of active pulmonary tuberculosis were negative.
The patient developed acute renal failure, managed by Dr. Trevor Jordan and his team of nephrologists via
hemodialysis. Mechanical ventilation, hemodialysis, and a nasoduodenal feeding tube were completed in an
attempt to provide further support; however, the patient continued to deteriorate. On January 15, 2015 at 0017
hours he became asystolic. Code blue was called. The patient underwent advanced cardiac life support with
multiple medications. He failed to respond to the advanced cardiac life support and was pronounced dead at
0041 hours on January 15, 2015. Permission for autopsy was denied.
1. Idiopathic pulmonary fibrosis with alveolitis.
2. History of tuberculosis.
3. Acute renal failure.
4. Hospital-acquired septicemia and fungemia secondary to multiple organisms.
Simon Williams, MD, Pulmonology
D: 01/15/2015
T: 01/15/2015