Case study

 

Ms. P is a 75-year-old woman with weakness and hypotension. Ms. P has a past medical history of coronary artery disease (CAD), hypertension and diabetes. She complains of weakness, anorexia, nausea and vomiting. Her initial vitals signs demonstrate a pulse of 110 bpm and BP of 85/55 mm Hg. She is having difficulty staying awake during the interview. Ms. P has vomited once this morning, but she ate and drank fluids normally the day before. She denies diarrhea, melena, or bright red blood per rectum. She denies any chest pain or pressure. She admits to urinary frequency over the last few days and chills and fever that began the previous night. On physical exam her temperature is 38.4°C. Her hands are cool but pulses are full with adequate capillary refill. Her neck veins are flat and lungs are clear. There is no JVD or S₃ gallop. She has costovertebral angle tenderness. Laboratory exam reveals a WBC of 15,000/mcL and her lactate was 3 mmol/L. Ms. P has several features that suggest sepsis, including her fever, urinary symptoms, and leukocytosis. An ECG shows no acute changes and a serum troponin level is undetectable. Her blood glucose is 150 mg/dL. After a 2 L fluid resuscitation, Ms. P’s BP increases to 100/50 mm Hg, her skin is warmer, and her pulses are bounding. Antibiotics were started for empiric treatment of urosepsis. After initial stabilization, hypotension recurred and urinary output dropped. She was transferred to the ICU. Four hours later her oxygenation deteriorated and a chest film revealed a diffuse infiltrate consistent with acute respiratory distress syndrome. She was intubated, cultures were drawn, and she was given IV fluids, norepinephrine, antibiotics, and mechanical ventilation. Her blood and urine cultures grew Escherichia coli. Over the next 24 hours, her BP stabilized. Seventy-two hours later she was extubated. She eventually made a full recovery.

SOAP Note

S- A 75 y/o woman with significant past medical history of coronary artery disease (CAD), hypertension, and diabetes, presents with complaints of weakness, anorexia, nausea, and vomiting. The patient states that, she is having frequency of ruination over the past few days, fever and chill since the last night, and one time vomitus this morning. She denies diarrhea, melena, rectal bleeding. The patient denies having any pressure or pain in her chest.

O- BP, 85/55 mmHg, Pulse, 110 bpm, temperature, 38.4°C, and pulse oximetry shows decreased PO2

General, not fully awake. Skin exam- cold hands, capillary refill less than 2 seconds bilaterally. cardiac exam- no S3 gallop or JVD. chest exam- lungs are clear on examination. Flat neck veins. abdominal and back exam- showed tenderness in her costovertebral angle. Lab results: Blood tests show, WBC= 15,000/mcL, Lactate= 3 mmol/L, Blood glucose= 150 mg/dL, Troponin is undetectable.EKG doesn’t show any recent changes. Blood and urine showed growth of E.coli. CXR shows diffuse Infiltrate.

A- The patient symptoms (fever and urinary frequency), her vitals (hypotension and tachycardia), and her lab results (leucocytosis, all these features indicate that the patient has sepsis due to UTI.

P- Intravenous fluid resuscitation and empiric antibiotics for treatment of urosepsis. The patient condition is deteriorated (hypotension recurred and her urine output decreases).The patient was transferred to the ICU. The patient developed ARDS. She is intubated, and treated with IV fluids, norepinephrine, antibiotics, and mechanical ventilation. The patient pressure returned to normal over the next day. Three days later she was extubated and she fully recovered.

Summary:

The first step in the management of a patient who presents with hypotension is to determine whether or not the patient is in shock. There are multiple features that indicate a patient is in shock such as tachycardia, tachypnea, hypotension, hypoperfusion of different organs, poor perfusion of skin and extremities, and altered mental status. The leading hypothesis in this case are septic shock, cardiogenic shock, hypovolemic shock. Shock is a life threatening condition, so hemodynamic stabilization must be started promptly without waiting for the results of the investigations to be completed. In this case, the patient has different features suggesting septic shock secondary to urinary tract infection. Her fever, frequency of ruination, costovertebral angle tenderness, and leukocytosis indicate that the patient is most likely has a urinary tract infection. The patient has the typical features of septic shock which are fever, tachycardia, tachypnea, hypotension , worm extremities, and pounding pulse after resuscitation with IV fluids. Even though the patient’s features indicate that she has a septic shock, Clinician must exclude other types of shock. The patient is diabetic, so she is vulnerable to have diabetic hyperosmolar state that can cause osmotic diuresis and subsequently hypovolemia. Finally, her diabetes and her prior history of coronary artery disease make her susceptible to have myocardial infarction and therefore cardiogenic shock. Cardiogenic shock or hemorrhagic shock often have cold extremities. The patient work up showed no evidence of heart attack. She also has no history of hemorrhage and she only vomited one time, so Ms. P is less likely to have either cardiogenic shock or hemorrhagic shock. Based on the symptoms, signs, and the laboratory results, we can conclude that Ms. P is most likely suffered septic shock.