Mr. Nate Johnson, a 73 year old male is a patient in the Intensive Care Unit whe

Question

Mr. Nate Johnson, a 73 year old male is a patient in the Intensive Care Unit where you are working. He was admitted with septic shock from a urinary tract infection. While providing oral care, you notice he is bleeding from his mouth. You notice that from old needle sites for lab draws and IVs, he is oozing blood around them.

1.         What questions do you want to ask?

2.         What are possible pathophysiologies that could be happening to Mr. Johnson? That is—brainstorm as many pathophysiologies as possible for him—and list them here

3.         After developing a list of pathophysiologies, sort them and rank them numerically. Explain your rationales for your choices to be ranked as you chose them.

4.         Test your hypothesis: List the diagnostic tests you would order to confirm or rule out the number one ranked choice.   Note: these are further lab results:  hematocrit of 34 percent, platelet count of 70,000, prothrombin time (PT) of 27 seconds, partial thromboplastin time (PTT) of 70 seconds, an international normalized ratio (INR) of 2.5, fibrinogen of 91 mg/dL and D-Dimer of 3.1 micrograms/mL   Are there any other lab tests you want?

5.         List at least two assumptions that you are making or testing. (This is hard—what are you taking for granted?) Remember an assumption is something you take for granted. Testing your assumptions can improve your thinking skills.

Explanation / Answer

Septic shock which occurs as a result of infection is a serious medical condition characterised by abnormalities in cellular metabolism and very low blood pressure.

1) Patients with septic shock will suffer from fevers, difficulty in breathing, nausea, vomitting, fatigue, anxiety and confusion. Questions specific to these signs and symptoms must be asked.

2) The various pathophysologies that can occur in this patient include disseminated intravascular coagulation (DIC) as a result of septic shock, dysfibrinogenemia, hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura and idiopathic thrombocytopenic purpura.

3)

4) The diagnosis of DIC usually includes a score based on the clinical and laboratory findings. labaratory findings are low plateletcount, prolonged prothrombin time, elevated fibrinogen levels and fibrin related markers. Apart from these, acid-base levels and oxygen content in blood can also be measured.

5) The assumptions that can be made in this patient are consumptive coagulopathy and multiorgan dysfunction syndrome (MODS) like cardiac failure and respiratory failure.

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