# Clinical Cases: Managing the Critically Ill Ward Patient

## Case 1: Sepsis from Urinary Source with Rapid Deterioration

### Clinical Presentation

**Patient Demographics:** 76-year-old female

**Chief Complaint:** "She's suddenly gotten much worse" - called by the nurse

**Clinical Context:**
You are the sub-intern covering the medicine floor at 2 PM. Mrs. Johnson was admitted yesterday for a urinary tract infection and was started on oral ciprofloxacin. The nurse pages you because the patient "looks different" and her vital signs have changed.

**History of Present Illness:**
Mrs. Johnson is a 76-year-old female with a history of type 2 diabetes mellitus, benign prostatic hyperplasia equivalent (urinary retention requiring intermittent catheterization), and mild dementia who was admitted 18 hours ago for dysuria, increased urinary frequency, and low-grade fever. She was started on ciprofloxacin 500 mg PO BID. This morning, she appeared comfortable and was eating breakfast. However, over the past 2 hours, the nurse notes she has become increasingly confused, less responsive, and her vital signs have deteriorated.

**Past Medical History:**
- Type 2 diabetes mellitus
- Dementia (mild, baseline oriented to person and place)
- Recurrent urinary tract infections
- Hypertension
- Osteoporosis

**Medications on Admission:**
- Ciprofloxacin 500 mg PO BID (started yesterday)
- Metformin 500 mg BID
- Lisinopril 10 mg daily
- Donepezil 10 mg daily
- Calcium/Vitamin D

**Physical Examination at Time of Call:**
- **Vital Signs:** Temperature 39.2C, HR 112 bpm, BP 88/52 mmHg, RR 26/min, SpO2 94% on room air
- **General:** Acutely ill-appearing, drowsy but arousable, confused
- **Cardiovascular:** Tachycardic, regular rhythm, warm extremities with bounding pulses
- **Lungs:** Clear to auscultation
- **Abdomen:** Soft, mild suprapubic tenderness
- **Neurologic:** Oriented to person only (baseline: person and place), following simple commands

### Recognition of Deterioration

**Early Warning Signs Identified:**
- Temperature spike from 37.8C to 39.2C
- Heart rate increase from 82 to 112 bpm
- Blood pressure drop from 124/76 to 88/52 mmHg
- New confusion beyond baseline
- Respiratory rate increase from 16 to 26/min
- Nursing concern about appearance

**Modified Early Warning Score (MEWS):**
- Respiratory rate (26): 2 points
- Heart rate (112): 2 points
- Systolic BP (88): 2 points
- Temperature (39.2): 1 point
- AVPU (Confused/Verbal): 1 point
- **Total MEWS: 8** (Critical - immediate escalation required)

### Immediate Actions (ABCDE Approach)

**Airway:** Patent, patient speaking
**Breathing:** Tachypneic but adequate; apply 2L NC to maintain SpO2 > 94%
**Circulation:** Hypotensive - establish second IV access, initiate fluid bolus
**Disability:** Altered mental status - check fingerstick glucose (result: 142 mg/dL)
**Exposure:** No rashes, wounds appear clean

### Stabilization and Escalation

**Immediate Interventions:**
1. Call for help - notified senior resident and attending
2. IV normal saline 30 mL/kg bolus (approximately 2L for 68 kg patient)
3. Obtain blood cultures x 2 (before antibiotics if possible)
4. Broaden antibiotics: Ceftriaxone 2g IV + Metronidazole 500 mg IV
5. Obtain stat labs: CBC, CMP, lactate, blood gas, urinalysis
6. Place Foley catheter for urine output monitoring
7. Continuous pulse oximetry

**Escalation Communication (SBAR):**

*"Dr. Martinez, this is [name], the sub-intern. I'm calling about Mrs. Johnson in room 412.*

**Situation:** *She's acutely deteriorating with septic shock from a urinary source.*

**Background:** *She's a 76-year-old admitted yesterday for UTI on oral cipro. She has diabetes and mild dementia.*

**Assessment:** *Her BP dropped to 88/52, heart rate is 112, temp spiked to 39.2, and she's now confused beyond her baseline. I'm concerned about urosepsis with inadequate source control.*

**Recommendation:** *I've started a fluid bolus, obtained cultures, and I'd like to broaden antibiotics to ceftriaxone and metronidazole. Should we consider ICU transfer if she doesn't respond to fluids?"*

### Inpatient Workup Results

**Laboratory Studies:**
- WBC 18,400/uL with 15% bands (left shift)
- Hemoglobin 11.2 g/dL
- Platelets 142,000/uL
- Sodium 134 mEq/L, Potassium 4.8 mEq/L
- BUN 42 mg/dL, Creatinine 2.1 mg/dL (baseline 1.0)
- Lactate 4.2 mmol/L
- Procalcitonin 8.6 ng/mL
- Urinalysis: Large leukocyte esterase, positive nitrites, >100 WBC/hpf, many bacteria

**Imaging:**
- CT abdomen/pelvis with contrast: Left hydronephrosis with 8mm obstructing ureteral stone, perinephric stranding concerning for pyelonephritis

### Diagnosis

**Primary Diagnosis:** Septic shock secondary to obstructive pyelonephritis (urosepsis)

**qSOFA Score:** 3 (altered mental status, SBP < 100, RR > 22)
**SOFA Score:** Elevated (renal dysfunction, altered mental status)

### Treatment Plan

**Immediate (Hour 1):**
1. Complete 30 mL/kg fluid resuscitation
2. Antibiotics administered within 1 hour of recognition
3. Urology consultation for emergent ureteral stent placement
4. Transfer to ICU for close monitoring

**If fluid-refractory (MAP < 65 after 2L):**
5. Initiate norepinephrine via central line
6. Arterial line for continuous BP monitoring

**Ongoing Care:**
- Repeat lactate in 2-4 hours (goal: lactate clearance)
- Monitor urine output (goal: > 0.5 mL/kg/hr)
- Daily assessment for de-escalation once cultures finalize
- Hold metformin and ACE inhibitor given AKI

### Clinical Image

![Chest X-ray showing bilateral infiltrates in a patient with sepsis](case_01_image.jpg)

**Image Description:** While this patient's chest X-ray was clear, severe sepsis can progress to acute respiratory distress syndrome (ARDS) with bilateral infiltrates. This image demonstrates the pulmonary findings that may develop in critically ill patients with sepsis.

**Image Source:** Wikimedia Commons - "Chest X-ray in influenza and H. influenzae"
- URL: https://commons.wikimedia.org/wiki/File:Chest_X-ray_in_influenza_and_Haemophilus_influenzae_-_annotated.jpg
- License: Creative Commons CC0 1.0 Universal Public Domain Dedication
- Author: Mikael Haggstrom, M.D.

---

## Case 2: Acute Hypoxic Respiratory Failure from COPD Exacerbation

### Clinical Presentation

**Patient Demographics:** 68-year-old male

**Chief Complaint:** "I can't breathe"

**Clinical Context:**
You are called to evaluate Mr. Davis, who was admitted 2 days ago for a COPD exacerbation. He had been improving on steroids and bronchodilators but now is in acute respiratory distress.

**History of Present Illness:**
Mr. Davis is a 68-year-old male with severe COPD (FEV1 32% predicted), oxygen-dependent at baseline (2L NC), and heart failure with reduced ejection fraction (EF 35%) who presented 2 days ago with increased dyspnea and productive cough. He was started on prednisone, nebulizers, and azithromycin. He was improving until 30 minutes ago when he developed acute worsening of dyspnea while getting up to use the bathroom.

**Past Medical History:**
- COPD (GOLD Stage IV)
- Heart failure with reduced EF (ischemic cardiomyopathy)
- Coronary artery disease, s/p stents
- Type 2 diabetes mellitus
- Former smoker (60 pack-years, quit 2 years ago)

**Current Medications:**
- Prednisone 40 mg daily
- Albuterol/ipratropium nebulizers Q4H
- Azithromycin 250 mg daily
- Carvedilol 12.5 mg BID
- Lisinopril 20 mg daily
- Furosemide 40 mg daily
- Metformin 1000 mg BID

**Physical Examination:**
- **Vital Signs:** Temperature 37.1C, HR 108 bpm, BP 152/88 mmHg, RR 32/min, SpO2 82% on 2L NC
- **General:** Severe respiratory distress, tripod positioning, using accessory muscles
- **Lungs:** Diffuse expiratory wheezes, prolonged expiratory phase, diminished breath sounds at bases
- **Cardiovascular:** Tachycardic, JVP elevated to 12 cm
- **Extremities:** 1+ pitting edema bilaterally (new)

### Immediate Assessment and Intervention

**ABCDE Primary Survey:**
- **Airway:** Patent, patient speaking in short phrases
- **Breathing:** Severe distress, SpO2 82% on 2L - immediately increase oxygen
- **Circulation:** Elevated JVP and new edema suggest fluid overload
- **Disability:** Alert, anxious, GCS 15
- **Exposure:** No concerning findings

**Immediate Actions:**
1. High-flow oxygen via non-rebreather mask (SpO2 improves to 89%)
2. Continuous pulse oximetry and cardiac monitoring
3. Stat nebulizer treatment (albuterol 2.5 mg + ipratropium 0.5 mg)
4. Call respiratory therapy for BiPAP setup
5. Stat portable chest X-ray
6. Stat ABG, BNP, troponin
7. Notify senior resident

### Workup Results

**Arterial Blood Gas (on 15L non-rebreather):**
- pH 7.28
- pCO2 62 mmHg
- pO2 58 mmHg
- HCO3 28 mEq/L

**Interpretation:** Acute on chronic hypercapnic respiratory failure with hypoxemia

**Additional Labs:**
- BNP 1,840 pg/mL (elevated from admission 620)
- Troponin I 0.08 ng/mL (mildly elevated)
- WBC 11,200/uL

**Chest X-ray:** Bilateral interstitial edema, cardiomegaly, small bilateral pleural effusions (new compared to admission)

### Diagnosis

**Primary Diagnosis:** Acute hypoxic and hypercapnic respiratory failure
- Contributing factors: COPD exacerbation + acute decompensated heart failure

**Differential for acute worsening:**
1. Flash pulmonary edema (most likely given exam and X-ray)
2. Pulmonary embolism (possible given immobility)
3. Pneumonia superinfection
4. Mucus plugging

### Treatment Plan

**Immediate Management:**
1. BiPAP initiated (IPAP 12, EPAP 5, FiO2 50%)
2. IV furosemide 80 mg (double home dose)
3. Continue nebulizers
4. Hold beta-blocker (carvedilol) temporarily
5. Consider CT-PA to rule out PE if not improving

**Response to Treatment (30 minutes):**
- SpO2 improved to 94% on BiPAP
- RR decreased to 24/min
- Patient reports feeling "better"
- Repeat ABG: pH 7.32, pCO2 54, pO2 72

**Escalation Considerations:**
- Discussed with attending: Patient stable on BiPAP, monitor closely
- ICU transfer if: Unable to wean BiPAP, worsening acidosis, altered mental status, need for intubation

### Clinical Image

![Chest X-ray showing pulmonary edema and cardiomegaly](case_02_image.jpg)

**Image Description:** Chest radiograph demonstrating cardiomegaly with bilateral pulmonary vascular congestion and interstitial edema, consistent with acute decompensated heart failure superimposed on COPD.

**Image Source:** Wikimedia Commons - "Congestive heart failure x-ray"
- URL: https://commons.wikimedia.org/wiki/File:Congestive_heart_failure_x-ray.png
- License: Public Domain

---

## Case 3: Acute Gastrointestinal Bleeding with Hemodynamic Instability

### Clinical Presentation

**Patient Demographics:** 62-year-old male

**Chief Complaint:** Large volume bloody stool

**Clinical Context:**
You are the sub-intern on night float when you receive an urgent page: "Room 508, patient just had a large bloody bowel movement, BP dropping."

**History of Present Illness:**
Mr. Chen is a 62-year-old male admitted 3 days ago for chest pain evaluation. Cardiac catheterization yesterday showed non-obstructive coronary artery disease, and he was started on aspirin and clopidogrel. He has been clinically stable until 10 minutes ago when he had a large maroon-colored bowel movement and felt lightheaded.

**Past Medical History:**
- Hypertension
- Type 2 diabetes
- History of peptic ulcer disease (H. pylori treated 5 years ago)
- Osteoarthritis

**Medications:**
- Aspirin 81 mg daily (started 3 days ago)
- Clopidogrel 75 mg daily (started yesterday)
- Metoprolol 25 mg BID
- Lisinopril 10 mg daily
- Omeprazole 20 mg daily (started on admission)
- Metformin 500 mg BID

**Physical Examination:**
- **Vital Signs:** HR 118 bpm, BP 86/54 mmHg, RR 20/min, SpO2 98% on RA
- **General:** Pale, diaphoretic, anxious
- **Cardiovascular:** Tachycardic, thready peripheral pulses
- **Abdomen:** Soft, mild epigastric tenderness, hyperactive bowel sounds
- **Rectal:** Maroon stool, guaiac positive

### Immediate Actions

**Recognition:** Class III hemorrhagic shock
- Heart rate > 100
- SBP < 90
- Altered mental status (anxiety, confusion)
- Estimated blood loss > 30%

**ABCDE Stabilization:**
1. **Airway:** Patent
2. **Breathing:** Adequate
3. **Circulation:**
   - Two large-bore IVs (18G or larger)
   - Type and crossmatch for 4 units pRBCs
   - Initiate crystalloid bolus (1L NS wide open)
   - Activate massive transfusion protocol consideration
4. **Disability:** Alert but anxious
5. **Exposure:** Pale skin, no external bleeding

**Immediate Orders:**
- STAT: CBC, CMP, coagulation studies, type and screen
- Transfuse 2 units pRBCs (don't wait for hemoglobin result given hemodynamic instability)
- IV pantoprazole 80 mg bolus, then 8 mg/hr infusion
- Hold aspirin and clopidogrel
- NPO
- Place NG tube to assess for upper GI source
- GI consultation for emergent endoscopy

### Escalation Communication

**Call to Senior Resident and Attending:**
"Mr. Chen in 508 is having an acute GI bleed with hemorrhagic shock. BP is 86/54, heart rate 118, he's pale and diaphoretic after a large maroon stool. He was just started on dual antiplatelet therapy after a cath. I've established two large-bore IVs, sent a type and crossmatch, started fluids, and I'm requesting emergent blood transfusion. I've also placed an NG tube - there's coffee-ground material, suggesting an upper source. I need you here and I'm paging GI for emergent EGD."

### Workup Results

**Laboratory Studies:**
- Hemoglobin 7.2 g/dL (admission: 13.8 g/dL)
- Platelets 186,000/uL
- INR 1.1
- BUN 58 mg/dL, Creatinine 1.4 mg/dL
- BUN/Cr ratio: 41 (elevated, suggesting upper GI bleed)

**NG Tube Aspirate:** Coffee-ground material, clears with lavage

### Diagnosis

**Primary Diagnosis:** Acute upper gastrointestinal bleeding with hemorrhagic shock
- Likely etiology: Peptic ulcer disease (reactivation in setting of dual antiplatelet therapy)

**Glasgow-Blatchford Score:** 14 (high risk, requires intervention)

### Treatment Plan

**Resuscitation:**
1. Transfuse to hemoglobin > 7 g/dL (> 8 if CAD symptoms)
2. Correct coagulopathy if present
3. Consider platelet transfusion if bleeding continues
4. Continuous monitoring in ICU setting

**Source Control:**
5. Emergent EGD within 12-24 hours (sooner if unstable)
6. Endoscopic therapy as indicated (clips, epinephrine, cautery)

**Post-Stabilization:**
7. Continue PPI infusion for 72 hours post-endoscopy
8. Discuss with cardiology regarding antiplatelet therapy hold duration
9. Test for H. pylori if ulcer confirmed

### Clinical Image

![Endoscopic view of bleeding gastric ulcer would be shown here](case_03_image.jpg)

**Image Description:** Upper GI bleeding commonly presents from peptic ulcer disease. Endoscopy reveals the source and allows therapeutic intervention.

**Image Source:** Radiopaedia - "Acute upper GI bleeding"
- URL: https://radiopaedia.org/articles/acute-upper-gastrointestinal-bleeding
- License: Educational use - Radiopaedia.org

---

## Discussion Questions

1. **Early Recognition:** In Case 1, what subtle signs might the nurse have noticed before the patient developed overt shock? How can you create a culture where nursing concerns are taken seriously?

2. **ABCDE Application:** In Case 2, the patient has both respiratory and cardiac components to their distress. How does the ABCDE approach help you systematically address both?

3. **Escalation Decisions:** In Case 3, at what point would you activate a rapid response team versus managing the situation with your immediate team? What factors influence this decision?

4. **Crisis Documentation:** How would you document the acute events in each of these cases? What elements are essential for both clinical care and medicolegal protection?

5. **Team Communication:** How would you debrief with the nursing staff after successfully stabilizing Case 1? What learning points would you highlight?