Shock Case Study
Shock Case Study Instructions:
Case Presentation:
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Mrs. Jones is an 88 year old female patient that was brought to the emergency department from Nursing Home via ambulance when found this morning with a decreased level of consciousness. She is rousable only to painful stimuli. The nursing team reports that she is usually alert and oriented. The staff also noted that Mrs. Jones had recently reported to the night nurse that she is voiding more frequently with a slight burning sensation on urination for the past few days.
Past Medical History
- Chronic Renal Failure
- MI (8 years ago)
- Type 2 DM
- Rheumatoid arthritis
Physical examination findings
- Vital signs: BP 78/40 mmHg, Pulse 138/min, RR 36/min and shallow, SaO2 87% on room air, Temp 39.4 0C Neuro
- Pupils are equal and reactive to light
- patient does not respond to voice, or touch, moans and withdraws to painful stimuli
Respiratory
- Increased respiratory rate with shallow respirations
- No in drawing , nasal flaring or use of accessory muscles
- Chest is clear throughout
- air entry decreased to the bilateral bases
Abdomen
- absent bowel sounds
Neck
- normal
Extremities
- cool and cyanotic peripheries
- weak and rapid palpable peripheral pulses
Skin
- Pale, cool and clammy Genitourinary
- Urine is cloudy and foul smelling
- 50 ml of cloudy urine to drainage with indwelling foley catheter insertion
Laboratory Results
| Tests | Results | Normal value |
| White blood cell count | 22.0 × 109 /L | 4.0-10.0 × 109 /L |
| Reb blood cell | 4.5 X 1012/L | 4.0 – 5.2 x 1012/L |
| Serum sodium | 137 mmol/L | 135-145 mmol/L |
| Serum chloride | 103 mmol/L | 98 – 106 mmol/L |
| Serum potassium | 5.5 mmol/L | 3.5-5.0 mmol/L |
| Blood urea nitrogen (BUN) | 7.0 mmol/L | 2.5-8.0 mmol/L |
| Serum Creatinine | 140 µmol/L | 70-120 µmol/L |
| pH arterial | 7.23 pH (metabolic acidosis) | 7.35-7.45 pH |
| Lactate | 4.8 mmol/L | 0.9 – 1.8 mmol/L |
Diagnostic test
- chest x-ray normal
- CT head-shows mild atrophic changes for age no presence of CVA or Hemorrhage
- Point of care urinalysis was positive for nitrite, 50+ leukocytes and large blood urine culture & sensitivity is positive for Escherichia coli (E. coli).
Admitting Diagnosis
Mrs. Jones was admitted to a critical care unit with Shock. On admission she was ordered the following medications in addition to her usual routine scheduled medications:
- Piperacillin / Tazobactam 3.375 g IV every 6 hours
- Continuous infusion of norepinephrine (Levophed®) and dopamine (Dopastat®) to maintain a MAP ≥ 60
- IV Pentaspan® 500 ml bolus given
- IV 0.9% NS bolus 2000ml over 2 hours to be followed by NS @ 100 ml/hr
Discussion Questions
- Explain each medication in detail (indications for use, mechanism of action and effects) in the treatment and management of Mrs. Jones shock and associated complications.
- Discuss the role of the normal saline and Pentaspan® bolus in the treatment and management of Mrs. Jones shock.
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