Case 18: Death Certification

A 68 year old female was admitted to hospital with a cold, pale and pulseless left arm and was diagnosed with an acutely ischaemic upper limb. She underwent left arterial embolectomy the same evening. The procedure was uneventful and circulation to the left arm was restored.

Day 2

In the early hours of the next day (approximately 8 hours later), the patient was found on the ward, slumped to the left side with new onset aphasia and left sided hemiparesis. Clinically, stroke was suspected and the patient was referred to the on-call stroke team.

A CT head was performed which showed no intracranial haemorrhage, space occupying lesion or acute territorial infarct. Thrombolysis was given. The patient was stable for the rest of the night with a GCS of 12/15 (E4, V2, M6).

Day 3

During the morning, the patient was hypertensive with BP 212/92, and a GTN infusion was commenced.  At around midday the patient was found to have collapsed.  CPR was commenced and 7 cycles were performed, however resuscitation was unsuccessful.

photo 5

Past Medical History: Atrial fibrillation, hypertension, angina, peripheral vascular disease (previous popliteal artery occlusion), mitral stenosis, and COPD.  The patient was on Warfarin.  The INR on admission was 1.4.

Question 1: As the team FY1 would you be able to complete this lady’s Death Certificate? What would you write

The team felt uncertain as to a cause of death in this case therefore the case was referred to the coroner and an autopsy was performed. The main autopsy findings were as follows:

The deceased was a Caucasian female with a BMI of 17. The main finding was severe atherosclerosis of the aorta with an aortic dissection originating at the aortic arch. This had led to a massive haemopericardium (blood in the pericardial space). The heart was enlarged and showed mild to moderate atherosclerosis of the coronary arteries but no significant stenosis or occlusion. The mitral valve showed severe calcification and stenosis. The left atrium was dilated and the atrial appendage contained thrombus.

The carotid bifurcations showed atherosclerosis and were narrowed by approximately 60% on the left and 50% on the right.  No changes were seen in the brain.

The lungs showed emphysematous changes. The gastrointestinal and genitourinary system were unremarkable.

Q2. Given the autopsy findings, what should be written on the death certificate in part 1 and in part 2?

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Dr Kate Fletcher, ST4 Histopathology, Barts & The Royal London Hospitals

Expert: Professor Michael Sheaff , Consultant Histopathologist, Barts & The Royal London Hospitals

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