Margins Orange

Case presentationSamane NabiEmergency medicine resident93.5.14

1A 82 y old man withThe chief complaint ofWEAKNESS coming to ED (HAZRAT_E_RASUL HOSPITAL)At 22:45 Pm92.12.22 2CC: Weakness PI:a 82 y old man was referred to ED With the chief complaint of generalized weakness which had been started 5 days before the entrance to ED.He complaint from intermittent burning retro sternal chest pain and epigastric pain that was radiated to the back with no relation to feeding It was accompanying with nausea, vomiting and cold sweating. content of vomiting was the eaten food and without blood and bile.He had no dyspnea. He had normal defication.no Melena. He had no fever.Patients with these symptom, was hospitalized for 2 days in another hospital before entrance to ED that due to the general deterioration, left center.3PMH: IHD +CCU addmition +HTN+DM-Dyspepsia or epigastric discomfort +

4DH & HH: Patient had not history of drug using.

Alcohol Smoking Opium 5P/E:VS:

PR: 97BP: 100/60RR:17T: 35 AxillaryO sat: 90%BS: 250

6Patient was conscious, ill and pail and he had cold sweating.No JVD.Lung: normalHeart: s1 and s2 were detected with no pathologic sounds or murmurAbdomen: Guarding- , Distention-, Mild Epigastric Tenderness+ Extremities: Extremity pulses were symmetrically full. 7What's your differential diagnosis?

8Example of a tableDifferential diagnosis1.Acute coronary syndrome2.Aortic dissection3.Acute pancreatitis4.Peptic ulcer perforation5.Bowel perforation6.GIB7.Electrolyte disorder9ECG:

10Patients with clinical suspicion of acute coronary syndrome, was treated.com + pomPlavixASAEnoxaparinIv nitroCaptoprilMetoralO2 with maskSerial ECG Internist consultation11laboratory data:WBC: 13400Neut: 90%HB: 16.2HCT: 44PLT: 262000VBG:PH: 7.43HCO3: 19.5PCO2: 30.1BE: -1012After 1 hour, the patient's clinical condition worsened.he opened the eyes with voicehis blood pressure was non measurable.Only carotid pulse was palpable.The patient was transferred to the resuscitation room13Central vein line was insertedCVP:2Foley catheter was insertedUrine out put: 0

14RUSH EXAM: IVC WAS CollapsedNo hypokinesia in heart, no tamponed no plural effusionIn inter loop and Morison patch there was non homogenous fluid

15In patient with septic shockVancomycin and meropenem was administered.After received of 2 liters normal slain CVP was 6 and urine out put was 200 ccBP: 100/60PR: 90Surgery consultation was done.CXR was taken. 16

17Bs: 119Na: 138K: 3.5BUN: 63Cr: 3.5PT: 14PTT: 35INR: 1CTNT : Negative18Surgery consultation:Spiral CT scan of abdomen & pelvic with IV and oral contrast19

20

21Patient in 7 am transferred to operation room with Peritonitis diagnosis due to hallo viscus perforation Operation report: D1 perforation with Purulent dischargeDistal gastrectomy with wound closing and gasterogegenostomy22

23After this surgery he transferred to SICU and because of anastomose leak and bowel evisceration Twice again operated.Patient any time win and after 30 days hospitalization and five times CPR expired.24shockin ED, shock is rarely listed as a primary diagnosis.Arterial hypotension, defined as a systolic blood pressure (BP) below 100 mm Hg, is measured at least one time in 19% of ED patients; however, diagnosed traumatic, cardiogenic, or septic shock is less common, constituting about 1 to 3% of all ED visits.25Patients in the ED are in shock with no obvious cause.Rapid recognition of shock requires immediate history and physical examinationIn general, patients with shock are ill, asthenic, pale, often sweating, and usually tachypneic or grunting, and often have a weak and rapid pulse.HR can be normal or low in shock.BP initially can be normal because of adrenergic reflexes.a single systolic BP less than 100 mm Hg in the ED is associated with a threefold increase in in-hospital mortality and a tenfold increase in sudden death.Shock can be strongly supported by the presence of a worsening base deficit or lactic acidosis.

The HR/systolic BP ratio may provide a better marker of shock than either measurement alone, a normal ratio is less than 0.8.Urine output provides an excellent indicator of organ perfusion.normal out put: >1.0 mL/ kg/hr , reduced: 0.5-1.0 mL/kg/hr, severely reduced: