This 79 yr old man admitted with feeling unwell and knee pains.A&E saw and got orthopedic doctor to have a look, suggesting that less likey septic arthritis. But joint aspiration done and awaiting MC&S.

Referred to medics. ( It was me)

Background history showed

• COPD on LTOT under respiratory physician
• CKD stage 4,
• LVF under cardiologist
• Gout

We got rhuematologist to see him.Hight Uric acid on repeat blood test. Colchisine started. Paracetamol and Codeine were regular analgesics.

Pain settling in next a couple of days. Joint aspiration came back as negative culture. we start Phyiso and Occupational input for discharge.

But during the last weekend, he got a sudden onset abdo pain and vomiting. I was asked to see.

Family was around. He looked miserable. Holding sick bowl in which foul smelling fluid.

I examined. Obs showed T 38C (Blood culture alrady done by nursing staff) . BP 150/70. Sinus tachycardia on ECG. Heart sound nil changed and nil significant. Abdomen was tense and Increased bowel sounds. I did PR examinaiotn, which was empty with a moderately englarged prostate. Nothing exciting.

But I did request Abdo XR and handed over to night team to review. XR showed distended bowel gas shadows. I asked my college to get surgeon to come and see. No obvious faecal load.

Their opinion was Pseudo obstruction for conservative management.

This morning (Monday), when I got to ward, nursing staffs reported that he was dying. It was true. During the weekend, on-calls already reviewed and they already gave a maximum approriate treatment. Family was around. I explained to them showing my empathy.

I started care path way for dying people. Iprescrinbe Diamorphine and Medazolam. I got Palliaitive team to come and review if any thing we needed to do more for his final time of life. They were happy with our plan.

He died afternoon while I was having a quick lunch. I certified.

Cause of death

1(a) Septicaemia

1(b) Psuedo intestinal obstruction

2. COPA and Heart failure

Pathologist was happy with my opinion of cause of death.

Rest in Peace Mr ,,,