Question

ACUTE CARE CASE STUDY

Patient and Setting: CM is a 45-year-old man, on an inpatient surgical unit

Chief Complaint: Sudden onset of nausea/vomiting, some difficulty breathing, change in status

History of Present Illness: CM is in hospital, day 2 post-ORIF fractured femur with significant haemorrhage and other soft tissue injuries, sustained in an MVA.  CM reports that his feet are swelling, (+) fatigue, (+) nausea and vomiting, and (+) SOB. He has also noticed a decrease in urine output , although he reports he has not been eating or drinking much.

Medical History: Hypertension (×5 yrs), MVA

Surgical History: N/A (other than current hospitalization)

Family History: Mother: DM; Father: died at age 50 due to MI

Social History: Ethanol intake: Nil; tobacco: once/month

Medications:

Lisinopril 40 mg PO BID for 5 years

ASA 81 mg po daily

Rosuvastatin 20mg po daily

Amlodipine 10 mg PO QD for 2 years

Ibuprofen 800 mg PO TID for back pain

Centrum One 1 tab PO QD

Allergies: Morphine (tongue swelling, itching, rash, SOB)

Physical Examination:

GEN: Well-developed, nourished man

VS: BP 190/100, HR 83, RR 26, T 37.3°C, Wt 80 kg, Ht 182 cm

HEENT: WNL

CHEST: Small crackles, rales, and wheezing

ABD: WNL

EXT: Bilateral LE swollen with fluid, 3+ pitting edema

NEURO: A & O ×2 (place, time)

Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and

Diagnostic Tests:

Na 132 K 5.9  

Hgb 88 Hct 0.34   Creatinine 189 BUN 23  

Blood Gas: pH 7.3; pCO2 40; HCO3 18; pO2 97

Urine Output: 300 mL/24 hr

CASE QUESTIONS:

1. What type of shock is CM at risk of? What are the mechanisms, signs and symptoms?

2. Identify 1 agent in CM’s medication profile with the potential to cause acute renal failure and describe the mechanism for kidney damage.

Rubric for the above 2 questions:

1. A detailed description of the mechanisms, signs &symptoms of the correct type of shock

2. One of CMs medications has been identified as having the potential to cause acute renal failure, along with a comprehensive description of the mechanism

Note: Please include the citation or websites link you get the answers from as I have to cite them for the assignment. Please answer these questions with great detail as they are 10 mark each for pathophysiology course. Thank you so much.

Answer 1

1. CM is prone to cardiogenic shock .

#. Cardiogenic shock

pump failure

cardiac function is impaired with inadequate CO, elevated filling pressures, and systemic vascular resistance

#. C ardiovascular related causes of cardiogenic shock

pump failure: AMI, CHF, cardiac arrest, acute fulminant myocarditis

obstruction: hypertrophic cardiomyopathy, severe valvular obstruction, pericardial tamponade, PE, pneumothorax

valve failure: aortic dissection, aortic or MR

refractory sustained tachy and bradyarrhythmias

toxic metabolic: beta blocker or Ca channel blocker OD, severe acidosis or hypoxemia.

#. Signs of cardiogenic shock :-

-tachycardia -hypotension -blood pressure <90mmHg or 30mmHg less than the patient's baseline -urine output <30ml/hour -cold, clammy skin -poor peripheral pulses -agitation, restlessness, confusion -pulmonary congestion -tachypnea -continuing chest discomfort

#. Medical management of cardiogenic shock:-

-pain relief and decreased myocardial oxygen requirements through preload and afterload reduction -drug therapy -intra-aortic balloon pump -immediate reperfusion

#. Drug therapy is used in cardiogenic shock :-

-morphine -diuretics -nitrates -vasopressor (dopamine) -analgesic -oxygen

2. Lisnopril is the agent which has caused the kidney damage and increased the serum creatinine levels .

ACE inhibitors are popular drugs for high blood pressure and heart failure. Because ACE inhibitors are metabolized by the kidneys, they do come with a risk of causing kidney damage, especially if you are dehydrated.