PATIENT PRESENTATION

Chief Complaint
The patient presents from her nursing home with altered mental status and
lethargy that has progressively worsened over the past 24 hours.

HPI
An 80-year-old woman who resides in a nursing home with a past medical history
that includes hypertension, advanced dementia, depression, and GERD presents to
the hospital. She was discharged last week from another hospital after being
treated for 5 days for a urinary tract infection. She did well through the first 2 days
after discharge but has become increasingly lethargic and drowsy in the past 24
hours. She is barely responsive at the time of assessment. She has had no reports
of fever, nausea, vomiting, or pain.

PMH
 HTN
 Advanced dementia
 Depression
 GERD

PSH
Noncontributory

FH
No HTN, DM, CAD, cancer, or vascular disease

SH
 Lives in a nursing home due to dementia
 No tobacco, alcohol, or illicit drug use

Medications
 Clonidine 0.2 mg/24 H transdermal patch every week
 Acetaminophen 500 mg PO Q 6 H as needed for pain/fever
  Lorazepam 0.5 mg PO Q HS
 Hydralazine 50 mg PO TID
 Omeprazole 20 mg PO QAM
 Rivastigmine 4.6 mg/24 H transdermal patch Q HS
 Levofloxacin 500 mg PO Q 24 H for 3 days (received 5 days of inpatient IV
therapy; completed total course 2 days ago)

Allergies
NKDA

Review of Systems
Unable to obtain due to patient’s mental status

Physical Examination
Gen
Unresponsive, thin appearing woman in acute distress

VS
BP 86/42 mm Hg, P 118–142 bpm, RR 14–35 breaths/min, T 35.6°C; SpO2: 94% on 8L
NC, Ht 5′3″, Wt 50.8 kg

Skin
Skin is warm, dry and pink, intact with no rashes or lesions

HEENT
 Normocephalic, no scleral icterus, no sinus tenderness

Neck/Lymph Nodes
Supple, nontender, no carotid bruits, no JVD, no lymphadenopathy

Lungs
Decreased air entry in the bases, otherwise clear, tachypnea

CV
Tachycardia, regular rhythm, no murmur, gallop, or edema
Abdomen
Soft, NT/ND, normal bowel sounds, no masses

Musculoskeletal
Normal range of motion and strength, no tenderness or swelling

Neuro
Responsive to painful stimuli at this time, unable to assess further

Labs

Na 135 mEq/L Mg 2.2 mg/dL WBC 19.3 × 103/mm3 Arterial blood gases
K 4.4 mEq/L Phos 3.1 mg/dL PMNs 72% pH 7.15
Cl 105 mEq/L Alb 2.3 g/dL Bands 18% PaCO2 28 mm Hg
CO2 12 mEq/L Alk Phos 55 IU/L Lymphs 5% PaO2 165 mm Hg
BUN 42 mg/dL T. bili 0.4 mg/dL Monos 5% HCO3 9.8 mEq/L
SCr 2.3 mg/dL AST 15 IU/L Hgb 12.2 g/dL Lactate 6.3 mmol/L
Glu 195 mg/dL ALT 10 IU/L Hct 38%
Ca 7.2 mg/dL Plt 205 × 103/mm3
Urinalysis
Color yellow, appearance cloudy, WBC 120/hpf, RBC 5/hpf, leukocyte esterase (+),
nitrite (+), epithelial cells 3–5/hpf, pH 5, bacteria 15/hpf

Other
ECG: sinus tachycardia (HR 122), QRS 98/QT-QTc 358/425

Clinical Course
After several hours in the ED, the patient’s blood pressure failed to improve despite
receiving 2 L of normal saline. Her mental status did not improve, and her urinary
output has been approximately 50 mL over past 3 hours (via foley catheter). She
was intubated and placed on mechanical ventilation secondary to respiratory
failure and concern for airway protection due to her mental status. The intensivist
is called to evaluate the patient. The intravenous medications she received in the
ED included:
  Normal saline 2 L (bolus)
 Etomidate 20 mg
 Succinylcholine 75 mg
 Midazolam 2 mg
 Norepinephrine 15 mcg/min continuous infusion begun
 Ceftriaxone 2 g × 1 dose

Assessment
An 80-year-old woman is admitted to the ICU with concerns of septic shock,
respiratory failure, and acute kidney injury secondary to a UTI.

QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of septic
shock?

1.b. What additional information is needed to fully assess this patient’s septic
shock?

Assess the Information

2.a. Assess the severity of septic shock based on the subjective and objective
information available.

2.b. Create a list of the patient’s drug therapy problems and prioritize them.
Include assessment of medication appropriateness, effectiveness, safety, and
patient adherence.

2.c. What ethical considerations are applicable to this patient?

Develop a Care Plan

3.a. What are the goals of pharmacotherapy for septic shock in this case?

3.b. What nondrug therapies might be useful for this patient’s septic shock?

3.c. What feasible pharmacotherapeutic options are available for treating septic
shock?
3.d. Create an individualized, patient-centered, team-based care plan to optimize
medication therapy for septic shock and this patient’s other drug therapy
problems. Include specific drugs, dosage forms, doses, schedules, and durations of
therapy.

3.e. What alternatives would be appropriate if the initial care plan fails or cannot
be used?

Implement the Care Plan

4.a. What information should be provided to the patient to enhance adherence,
ensure successful therapy, and minimize adverse effects?

4.b. Describe how care should be coordinated with other healthcare providers.

Follow-Up: Monitor and Evaluate

5. Explain how to monitor and evaluate the care plan for medication
appropriateness, effectiveness, safety, and patient adherence by using clinical and
laboratory data, patient feedback, and other information.

SELF-STUDY ASSIGNMENTS
1. Review the medical literature supporting use of regular insulin infusions to
achieve glycemic control in patients with sepsis focusing on target blood glucose
values.

2. Review the medical literature on use of corticosteroids in sepsis focusing on

dosing, administration, and diagnosis of sepsis-induced adrenal insufficiency.