Core IM AHD Shock and Hypotension PBL

These cases are meant to be done in small groups but can be done individually if you wish.

Feel free to pick a ‘shock themed’ group name and include that in the form so I can address your answers when we take up the cases! Names are optional but I would like everyone to make a group or individual submission. You will learn a lot more from the exercise if you force yourself to “pick a horse” and commit to a decision for each question. It’s ok (actually good) to be wrong because that will help us figure out where the gaps in our knowledge are and fill them in.

The idea with these cases/questions to get you thinking about important concepts in the diagnosis and management of shock and to appreciate the importance of understanding the underlying physiology in order to individualize management.

Case Description

Jack Smith is a 65 y/o M with DLBCL. He has completed his first round of RCHOP 2 weeks ago and was seen in the cancer clinic yesterday for persistent diarrhea and some intermittent nausea and abdominal pain. At that visit, he was afebrile and initially had a HR of 110 with BP 90/50.

He was given a 2 L bolus of NS and felt much better, his vital signs normalized and so he was sent home with a prescription for zofran and told to come back if he felt worse, developed fever, chills, etc.

He came back to the ED this morning after being found in bed confused and incontinent of stool.

His other medical history includes: GERD, CAD with NSTEMI in 2010 (1 x DES to RCA), DM2.

Medications:

ASA 81 mg po daily

Metformin 1000 mg po bid

Zofran 4 mg po q8h PRN

Mr C. Rosis is a 54 y/o admitted 2 days ago with progressive orthopnea and PND.

For the last month he has been sleeping in a chair and has been breathless walking up stairs. This is his third admission, having left AMA on two other occasions the same day he was admitted.  He was previously diagnosed with alcoholic cardiomyopathy 9 years ago, at which time he had a LVEF of 39%.

His admitting diagnosis is CHF and the day team has been diuresising him. He is on Connell 9.

Current medications:

Metoprolol 25 mg po bid

ivabdadine 2.5 mg po bid

lasix 40 mg po bid

You are the non-take R1 on call, you are paged by the RN who is concerned that the patient looks “terrible”. Over the phone you are told that the patient has a weak pulse with a HR of 90 and they are unable to get a BP reading with the automatic cuff.

When you arrive, the RACE nurse is there, they were able to get a BP of 90/75, SpO2 via forehead probe is only reading intermittently at 95% on 2L NP.

On exam, he is ashen, profoundly diaphoretic with cool extremities. He is confused (opens eyes to voice, oriented to person only).

Chest is clear. Heart sounds are faint, there is a Gr III/VI pan systolic murmur.

Capilliary refill is 3-4 seconds.

Abdomen is soft and non-tender.

Labs…

Mr C. Rosis is a 54 y/o admitted 2 days ago with progressive orthopnea and PND.

For the last month he has been sleeping in a chair and has been breathless walking up stairs. This is his third admission, having left AMA on two other occasions the same day he was admitted.  He was previously diagnosed with alcoholic cardiomyopathy 9 years ago, at which time he had a LVEF of 39%.

His admitting diagnosis is CHF and the day team has been diuresising him. He is on Connell 9.

Current medications:

Metoprolol 25 mg po bid

ivabdadine 2.5 mg po bid

lasix 40 mg po bid

You are the non-take R1 on call, you are paged by the RN who is concerned that the patient looks “terrible”. Over the phone you are told that the patient has a weak pulse with a HR of 90 and they are unable to get a BP reading with the automatic cuff.

When you arrive, the RACE nurse is there, they were able to get a BP of 90/75, SpO2 via forehead probe is only reading intermittently at 95% on 2L NP.

On exam, he is ashen, profoundly diaphoretic with cool extremities. He is confused (opens eyes to voice, oriented to person only).

Chest is clear. Heart sounds are faint, there is a Gr III/VI pan systolic murmur.

Capilliary refill is 3-4 seconds.

Abdomen is soft and non-tender.

Labs…