Reference no: EM133510794

Case: Mrs. S. is a 69-year-old critically ill woman who experienced a major hypotensive episode, secondary to gastrointestinal hemorrhage and hypovolemic shock.

Mrs. S. had a massive gastrointestinal bleed last night. The bleeding has stopped, and she is now hemodynamically stable. However, her MAP (Mean Arterial Pressure) fell to less than 50 mmHg for more than 40 minutes.

Mrs. S. has no unexpected complaints. She is very relieved that her stomach ulcer has stopped bleeding. Otherwise, she has only minor discomforts associated with treatment. Mrs. S.'s lying heart rate is 95 and blood pressure 138/84; standing heart rate is 100 and blood pressure 134/78. She is without jugular venous distension and experiences only fleeting vertigo when sitting. Mrs. S. has no dependent edema, her respiratory rate is 20 and unlabored, and her lungs have transitory rales that clear with coughing. Unfortunately, her urine output has been sluggish (15-20 ml/hr) overnight and has fallen to 10 ml/hr for the last 4 hours. The urine is a clear yellow. Urine specific gravity is 1.010, sodium 50 mEq/L, serum blood urea nitrogen 43 mg/dl, creatinine 1.3 mg/dl.

Question 1. The probable reason for a drop in GFR and subsequent oliguria while Mrs. S. was bleeding was: (Choose the correct answer)

Rapid transfusions
Systemic acidosis
Systemic hypoxia
Lack of renal perfusion

Question 2. Mrs. S.'s renin mechanism and the release of two other hormones (aldosterone and Anti-diuretic hormone (ADH)) were called into play during her hypovolemic shock episode. Explain how Mrs. S.'s renin mechanism and the action of Aldosterone and ADH protected vital organs such as the brain and heart from experiencing a critical decrease in blood flow.

Question 3. Two days later, Mrs. S. is a little breathless, irritable, and tired. She complains of thirst, nausea mild pruritis, weakness and shortness of breath. Her heart rate is 86, and her blood pressure 168/92. She has gained 6 kg and has pitting edema around her ankles. Pulses are full and she has an S3 heart sound (gallop) Her lungs have fine crackles one third of the way up posteriorly. Her respiration is 24, deep and slightly labored. She is weak and lethargic. Mrs. S.'s electrocardiogram shows tall, peaked T waves and widening intervals. Her serum blood urea nitrogen is 180 mg/dl, creatinine 10 mg/dl, potassium 7.5 mEq/L. Arterial blood pH is 7.20, PaCO2 20 mmHg, NaHCO3 10 mEq/L, PaO2 66 mmHg on room air.

Hemodialysis has become necessary. Blood purification due to malfunctioning kidneys

Question 4. What current signs and symptoms (those found in Paragraph B) would you attribute to Mrs. S.'s elevated potassium? (Choose the correct answer)

Electrocardiogram changes, weakness, dyspnea, and nausea
Pruritis, S3 gallop, pitting edema, and weight gain
Thirst, hypertension, peaked T waves, oliguria, and weight gain
Pruritis, acidosis, S3 gallop, weight gain, and nausea.
Ten days later, Mrs. S. is feeling better. She is able to eat. Mrs. S.'s vital signs are closer to her normal baseline. Her edema, both peripheral and pulmonary, is gone, as are weakness and pruritis. Her blood urea nitrogen is 40 mg/dl and creatinine 6.0 mg/dl. Mrs. S.'s metabolic acidosis is controlled. Her urine output has increased dramatically and ranges between 100 and 150 ml/hr.

Seven months post discharge from the hospital, her blood urea nitrogen plateaued at 27 mg/dl and her creatinine at 1.4 mg/dl. Mrs. S. has finally recovered.

Question 5. Using the lab results data and by comparing how the lab results changed over time, list a few of Mrs. S.'s acid-base imbalances and how her body compensated.