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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Develop a plan for implementing fluid or medication therapies for treating a patient in the initial stages of shock.

  • Outline the major parameters used to monitor hypovolemic shock and its treatment.

  • List the major disadvantages of using only isolated hemodynamic recordings, such as blood pressure measurements, for monitoring the progression of shock.

  • Compare and contrast fluids and medications used for treating hypovolemic shock.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m beat. I have vomited four times in the last 24 hours and had diarrhea last evening. Now is not a great time to get sick since I’m in college and have finals next week.”

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HPI

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Four days PTA, Mr Hobbs, a 20-year-old college student, had abdominal pain that he attributed to a flare-up in his Crohn disease due to the stress of final examinations. He has an infliximab infusion scheduled for next week; he has them every 8 weeks and does not miss these infusions. However, he admits that he forgets to take his oral medications now that he lives away from his family. When he has Crohn pain, he does not feel like eating since eating causes more stomach pain. Furthermore, he has vomiting and diarrhea, which is aggravated by food intake. Per the recommendation of his community pharmacist, Mr Hobbs purchased a commercially available rehydration solution and attempted to drink the small but frequent volumes recommended by his pharmacist, but he could not keep up with fluid losses. His primary care physician referred him to the local hospital for rehydration and further evaluation.

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PMH

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  • Crohn disease, diagnosed 4 years ago

  • Ankylosing spondylitis, diagnosed 3 years ago

  • Pulmonary coccidioidomycosis (small ill-defined mass in lungs with positive cocci titers), diagnosed 1 year ago

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FH

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Noncontributory

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SH

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Does not smoke or use illicit drugs; admits to occasional ETOH use at parties

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Meds

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  • Infliximab 300 mg by IV infusion over 3 hours every 8 weeks

  • Azathioprine 100 mg PO daily

  • Fluconazole 400 mg PO daily

  • Fish oil (unknown strength) one capsule PO BID

  • Multivitamin one tablet PO daily

  • Whey shakes for protein supplementation, one shake PO daily

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All

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NKDA

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ROS

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The patient has had a recent increase in weight over the past month (6 kg), although this has decreased by 2 kg in the last few days. Hearing is intact with no vertigo. No dizziness or fainting episodes. Colorless sputum. No chest pain or dyspnea, but heart has been “racing.” Has had one episode of diarrhea and four episodes of vomiting with abdominal pain in the past 24 hours. No musculoskeletal ...

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