Master Priority Decision-Making Through Complex Patient Scenarios
From Simple Pain to Septic Shock
PMH: HTN, Hyperlipidemia
When Ulcers Turn Deadly
PMH: RA on chronic NSAIDs, GERD
Post-Op Complications Mounting
PMH: Osteoporosis, AFib on warfarin
From Constipation to Crisis
PMH: Colon CA s/p resection, DM2
When Simple Becomes Severe
PMH: CKD Stage 3, CHF
Cholecystitis to Pancreatitis
PMH: Obesity, Type 2 DM
Robert Chen, 55-year-old male
Initial Presentation:
Robert arrives at the ED at 3 AM with sudden onset right flank pain that started 2 hours ago. He's pacing, unable to find a comfortable position. He rates pain 9/10, describes it as "sharp and stabbing." No fever. Urine appears pink-tinged.
VS: BP 165/95, HR 108, RR 22, Temp 98.6°F
The patient is in severe pain (9/10). Pain management is the immediate priority. While the other options are important, addressing severe pain comes first. The elevated BP is likely due to pain and will improve with analgesia.
30 minutes later:
After ketorolac, Robert's pain is 6/10. UA shows: RBC >50/hpf, WBC 5-10/hpf, no bacteria. CT scan confirms 7mm stone at right ureteropelvic junction with moderate hydronephrosis.
Current VS: BP 148/88, HR 96
IV fluids help flush the stone and prevent further kidney damage from obstruction. Tamsulosin is helpful but fluids are more urgent. Lithotripsy isn't emergent for a 7mm stone. Foley isn't necessary at this point.
2 hours later:
Robert suddenly develops severe nausea and vomits twice. He's now having chills. Pain has increased to 10/10 despite medication.
VS: BP 92/58, HR 122, RR 26, Temp 102.8°F
The patient is developing septic shock (hypotension, tachycardia, fever). This requires immediate fluid resuscitation and rapid response activation. Cultures are important but hemodynamic stabilization comes first.
Rapid Response arrives:
Two large-bore IVs placed, NS bolus running. Blood cultures drawn. Labs show: WBC 18,000, Cr 2.4 (baseline 1.0), lactate 4.2.
Urology recommends emergent nephrostomy tube placement.
In sepsis, antibiotics should be given within 1 hour. This is time-critical. Consent is important but can be obtained en route. No mention of coagulopathy. Arterial line can wait until OR/ICU.
Post-nephrostomy tube placement:
Robert is in ICU. Nephrostomy draining purulent urine. On norepinephrine for BP support. New labs: platelets 68,000 (was 250,000), PT/INR elevated, fibrinogen low.
DIC is characterized by low platelets, elevated PT/INR, and low fibrinogen in the setting of severe sepsis. This is a life-threatening complication requiring immediate treatment.
ICU Day 2:
Robert is intubated for respiratory failure. On CRRT for acute kidney injury. Nephrostomy output decreasing. Blood cultures growing E. coli.
Decreasing output from a nephrostomy tube usually indicates mechanical problems. With ongoing sepsis and kidney injury, urine production should be maintained. Tube patency must be verified immediately.
ICU Day 3:
Nephrostomy tube flushed and patent. Robert developing purple discoloration of fingers and toes. Lactate rising despite antibiotics. Family asking about prognosis.
Purpura fulminans is a severe manifestation of DIC causing purple discoloration and tissue necrosis. This indicates critical illness with high mortality. Family should be updated about grave prognosis.
ICU Day 5:
Robert showing improvement. Off pressors, extubated, making urine. Stone passed spontaneously. Ready for step-down unit. Family grateful but asking how to prevent this.
Adequate hydration is the most important prevention strategy for kidney stones. Calcium restriction is not recommended. Vitamin C can increase stone risk. Physical activity is beneficial.
Your final score: 0/8
Percentage: 0%
Margaret Williams, 68-year-old female
Initial Presentation:
Margaret presents with 3-day history of worsening epigastric pain. Takes ibuprofen 800mg TID for RA. This morning, she vomited "coffee grounds" material. Feels dizzy when standing.
VS: BP 105/70 lying, 88/58 standing, HR 98 lying, 118 standing, RR 20
The patient has orthostatic hypotension indicating significant volume loss. Immediate IV access and fluid resuscitation is the priority to maintain perfusion. Labs and medications are important but come after establishing vascular access.
30 minutes later:
Two 18G IVs placed, 1L NS infusing. Labs back: Hgb 6.8 g/dL (baseline unknown), platelets 380,000, INR 1.1. She vomits bright red blood (~200mL).
VS: BP 95/60, HR 125
With Hgb 6.8 and active bleeding, immediate transfusion is critical. Octreotide is for variceal bleeding. NG lavage doesn't stop bleeding. INR is normal, so vitamin K not indicated.
1 hour later:
Blood transfusing. GI consulted for urgent EGD. Margaret suddenly complains of severe, sharp epigastric pain radiating to her back. Abdomen rigid.
VS: BP 82/50, HR 138, RR 28, Temp 99.8°F
Sudden severe pain with rigid abdomen indicates perforation. This is a surgical emergency requiring immediate intervention. The presentation is classic for perforated ulcer.
STAT Response:
Surgeon at bedside. Portable CXR shows free air under diaphragm. Patient needs emergent surgery. Current Hgb 7.2 after 1 unit PRBC.
With perforation, antibiotics must be started immediately to prevent peritonitis. Blood can continue in OR. Foley will be placed in OR. Consent important but antibiotics are time-critical.
Post-op Day 1:
Graham patch repair completed. Margaret is intubated in ICU. Abdomen distended, no bowel sounds. NG output bilious. WBC 22,000, lactate 3.8.
Elevated WBC, lactate, and abdominal distension suggest peritonitis despite surgery. This requires aggressive antibiotic therapy and possible re-exploration.
Post-op Day 2:
Margaret developing respiratory distress. CXR shows bilateral infiltrates. P/F ratio 150. Requiring increased ventilator support.
VS: BP 88/52 on norepinephrine, HR 115
Bilateral infiltrates with P/F ratio <200 in setting of sepsis indicates ARDS. This is a severe complication requiring lung-protective ventilation strategies.
Post-op Day 3:
Margaret on multiple pressors, CRRT for AKI. Family meeting held. Prognosis poor. Abdomen increasingly distended with minimal NG output.
Progressive distension despite NG suction suggests abdominal compartment syndrome, a life-threatening complication requiring decompressive laparotomy.
Post-op Day 5:
Bladder pressure 28 mmHg (normal <12). Oliguria despite CRRT. Peak airway pressures rising. Pupils fixed and dilated.
Fixed dilated pupils suggest brain herniation from increased ICP, likely due to severe hypoxia and hypotension. This indicates grave prognosis.
Family Meeting:
Neurology confirms brain death. Family struggling with decision. They ask "How did a stomach problem lead to this?"
Honest, clear explanation of the cascade: perforation → peritonitis → sepsis → multi-organ failure → brain death helps family understand while maintaining compassion.
Learning Point:
Margaret's case started with chronic NSAID use for RA. What's the most important prevention strategy for NSAID-related GI complications?
Evidence supports using lowest effective NSAID dose with PPI prophylaxis in high-risk patients. Food doesn't prevent ulcers. Acetaminophen ineffective for RA. PRN use doesn't reduce risk.
Your final score: 0/10
Percentage: 0%
Dorothy Thompson, 82-year-old female
Initial Presentation:
Dorothy found on bathroom floor by daughter. Right leg shortened and externally rotated. Last seen normal 2 hours ago. Takes warfarin for AFib.
VS: BP 168/92, HR 88 irregular, RR 20, crying in pain