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Case presentation Samane Nabi Emergency medicine resident 93.5.14

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A 82 y old man with The chief complaint of WEAKNESS coming to ED (HAZRAT_E_RASUL HOSPITAL) At 22:45 Pm 92.12.22

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CC: 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.

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PMH: IHD + CCU addmition + HTN+ DM- Dyspepsia or epigastric discomfort +

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DH & HH: Patient had not history of drug using. Alcohol Smoking Opium

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P/E: VS: PR: 97 BP: 100/60 RR:17 T: 35 Axillary O sat: 90% BS: 250

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Patient was conscious, ill and pail and he had cold sweating. No JVD. Lung: normal Heart: s1 and s2 were detected with no pathologic sounds or murmur Abdomen: Guarding-, Distention-, Mild Epigastric Tenderness+ Extremities: Extremity pulses were symmetrically full.

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What's your differential diagnosis?

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Example of a table Differential diagnosis 1.1.Acute coronary syndrome 2.Aortic dissection 3.Acute pancreatitis 4.Peptic ulcer perforation 5.Bowel perforation 6.GIB 7.Electrolyte disorder

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ECG:

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Patients with clinical suspicion of acute coronary syndrome, was treated. com + pom Plavix ASA Enoxaparin Iv nitro Captopril Metoral O2 with mask Serial ECG Internist consultation

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laboratory data: WBC: 13400 Neut: 90% HB: 16.2 HCT: 44 PLT: 262000 VBG: PH: 7.43 HCO3: 19.5 PCO2: 30.1 BE: -10

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After 1 hour, the patient's clinical condition worsened. he opened the eyes with voice his blood pressure was non measurable. Only carotid pulse was palpable. The patient was transferred to the resuscitation room

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Central vein line was inserted CVP:2 Foley catheter was inserted Urine out put: 0

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RUSH EXAM: IVC WAS Collapsed No hypokinesia in heart, no tamponed no plural effusion In inter loop and Morison patch there was non homogenous fluid

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

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Bs: 119 Na: 138 K: 3.5 BUN: 63 Cr: 3.5 PT: 14 PTT: 35 INR: 1 CTNT : Negative

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Surgery consultation: Spiral CT scan of abdomen & pelvic with IV and oral contrast

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

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After 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.

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shock in 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.

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Patients in the ED are in shock with no obvious cause. Rapid recognition of shock requires immediate history and physical examination In 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.

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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: