With this case answer the questions that provide:

Chief Complaint

The patient presents from her nursing home with altered mental status and lethargy that has progressively worsened over the last 24 hours.

HPI

Ruth Carter is an 80-year-old Caucasian female who resides in a nursing home with a past medical history that includes hypertension, dementia, chronic kidney disease, depression, and GERD. She was discharged last week from another hospital after being treated for 5 days for a urinary tract infection. Patient did well through the first two days after discharge, but has become increasingly lethargic and drowsy in the last 24 hours. Patient is barely responsive at the time of assessment. Patient has had no reports of fever, nausea, vomiting, or pain.

PMH

HTN

Dementia

CKD, stage II

Depression

GERD

SH

Non-contributory

FH

No HTN, DM, CAD, cancer, or vascular disease

SH

Lives in a nursing home due to dementia

No tobacco, alcohol, or illicit drug use

Medications PTA

Clonidine 0.2 mg/24 H transdermal patch every week

Acetaminophen 500 mg PO Q 6 H as needed for pain/fever

Lorazepam 0.5 mg PO QHS

Hydralazine 50 mg PO TID

Omeprazole 20 mg PO QAM

Rivastigmine 4.6 mg/24 H transdermal patch Q HS

Levofloxacin 500 mg PO Q 24 H for 3 days (received 5 days of inpatient therapy; completed total course 2 days ago)

Allergies

NKDA

Review of Systems

Unable to obtain due to patients mental status

Physical Exam

Gen

Unresponsive, thin appearing female in acute distress

Vital Signs

BP 86/42 mm Hg, P 118142 bpm, RR 1435 bpm, T 35.6C; SpO₂: 94% on 8 L NC, Ht 53, Wt 50.8 kg

Skin

Skin is warm, dry and pink, intact with no rashes or lesions

HEENT

Normocephalic, no scleral icterus, no sinus tenderness

Neck/Lymph Nodes: Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy

Lungs

Decreased air entry in the bases, otherwise clear, tachypnea

CV

Tachycardia, regular rhythm, no murmur, gallop, or edema

Abdomen

Soft, NT/ND, normal bowel sounds, no masses

Musculoskeletal

Normal range of motion and strength, no tenderness or swelling

Neuro

Responsive to painful stimuli at this time, unable to assess further

Lab

Na 135 mEq/L	Mg 2.2 mg/dL	WBC 19.3 103/mm3	pH 7.15
K 4.4 mEq/L	Phos 3.1 mg/dL	PMNs 72%	PaCO2 28 mm Hg
Cl 105 mEq/L	Alb 2.3 g/dL	Bands 18%	PaO2 165 mm Hg
CO2 12 mEq/L	Alk Phos 55 IU/L	Lymphs 5%	HCO3 9.8 mEq/L
BUN 42 mg/dL	T. bili 0.4 mg/dL	Monos 5%	Lactate 6.3 mmol/L
SCr 2.3 mg/dL	AST 15 IU/L	Hgb 12.2 g/dL
Glu 195 mg/dL	ALT 10 IU/L	Hct 38%
Ca 7.2 mg/dL		Plt 205 103/mm3

Urinalysis

Color: Yellow

Appearance: Cloudy

WBC 12/hpf

RBC 5/hpf

Leukocyte esterase: Positive

Nitrite: Positive

Epithelial cells: 35/hpf

pH 5

Bacteria 15/hpf

Other

EKG: sinus tachycardia (HR 122), QRS 98/QT-QT_c 358/425.

Clinical Course

After several hours in the ED, Ms Carters blood pressure failed to improve despite receiving 2 liters of normal saline. Her mental status did not improve and her urinary output has been approximately 50 mL over last 3 hours (via foley catheter). She was intubated and placed on mechanical ventilation secondary to respiratory failure and concern for airway protection due to her mental status. The intensivist is called to evaluate the patient. The intravenous medications she received in the ED included:

Normal saline 2 liters

Etomidate 20 mg

Succinylcholine 75 mg

Midazolam 2 mg

Norepinephrine 15 mcg/min

Ceftriaxone 2 gm 1 dose

Assessment

An 80-year-old-female is admitted to the ICU with concerns of septic shock, respiratory failure, and acute kidney injury secondary to a UTI.

Answer this questions

Problem Identification

1.a. Create a list of this patients drug therapy and disease state problems.

1.b. What information (signs, symptoms, laboratory values) indicates the presence or severity of the problem or disease?

Desired Outcome

2. What are the goals of patient care in this case?

Therapeutic Alternatives

3.a. What interventions and/or therapies should be accomplished as soon as severe sepsis or septic shock is suspected or diagnosed in a patient?

3.b. What type of fluid therapy should be recommended for resuscitation of septic patients?

3.c. When should a vasopressor agent be considered in the treatment of sepsis-induced hypotension and which agents are appropriate?

3.d. When should you consider inotropic agents in this patients therapy, and which agents are appropriate?

3.e. What is the role of corticosteroid therapy in septic shock?

3.f. What additional supportive care issues should be implemented for all severe sepsis or septic shock patients?

3.g. What ethical considerations are applicable to this patient?