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Life Threatening? No
Write-up: Patient got sick with flu like symptoms on 10/24 around 1PM, went to hospital with trouble breathing around 9PM, was pronounced deceased at 1AM on 10/25. 10/27/09 ER and hospital records received service date 10/25/09. Assessment: Death due to septic shock secondary to infection of unknown source. Asplenia. Patient had nausea, vomiting, chills, stomach cramping, diarrhea, tachypnea, hypotension, diaphoresis for one day. Limited oral intake. Became cyanotic around lips, fingernails, and toenails. Presented to ER hypotensive, hypoxic, no longer breathing. Tachycardia. Cardiac arrest presenting as pulseless electrical activity (PEA). Hyperacidemia. Resusitation. Intubated and transported to ICU. Bilateral infiltrates consistent with acute respiratory distress syndrome. End-organ damage including kidneys and brain. Repeated PEA. No pulse. Mottling of head and extremities. Overwhelming sepsis and septic shock. Patient expired. 11/02/09: Primary Care Records received for date of service 10/9/09. Seasonal flu vaccine record received VAERS updated. Assessment: Presented with vaginal bleeding x 3 weeks, had hx. of D&C in 08 2/2 heavy vaginal bleeding. Also presented with a cold that started 5 days prior, afebrile at visit. Seasonal Flu vaccine given. 11/05/09 Diagnostic/lab results received. IDPB Test results: Lung section shows increased interstitial inflammatory infiltrates. Heart section shows focal interstitial edema and extravasation. No evidence of myocarditis. Liver section shows increased portal infiltrates and dilated sinusoids with Kupffer cell hyperplasia. Special stains: Scattered gram-positive cocci in lung, heart and liver. Immunohistochemical Assays: (+) Strep penumoniae in lung, heart and liver. (-) for influenza virus. PCR Assays: Negative for 2009 pandemic H1N1 influenza A virus. PCR for penumoniae pending. 12/14/09 Autopsy Records receivedI. DOD 10/25/09. Final Cause of Death: Streptococcus Pneumonia Sepsis. II. Hemolytic Anemia with Splenectomy. Additional information abstracted: Arteriovenous malformation of brain. Cholecystectomy remote. Blood cultures (+) for streptococcus pneumonias.
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