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Medical Department, Penang General Hospital

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1 Medical Department, Penang General Hospital
SHOCK/ HYPOTENSION Medical Department, Penang General Hospital

2 Case Senario 1: 68 year old lady, known case of diabetes mellitus for 15 years, hypertension, bilateral knees osteoarthritis. On regular medications from Klinik Kesihatan. 1 week history of poor appetite, lethargic, cough. Noted by family to be confused, SOB on the day of admission. BP: 90/50mmHg HR : 120 bpm

3 What other information from the history do you need?
What are the other vital signs that you want to know?

4 GCS: 11/15 BP: 90/50mmHg PR: 120bpm, not feeble Temperature: 38 degree celsius RR: 40breath/ min, SpO2 under room air: 93% Reflomet: 20mmol/L Clinically pale, dehydrated. Lungs: Lt basal crepitation with occasional rhonchi. CVS: NAD CNS: moving all 4 limbs (unable to follow command) PA: mild tenderness at epigastric region, otherwise soft. BS normal.

5 Why is her GCS low? Why is she tachycardic but with a pulse which is not feeble? Why is she tachypnoeic? What do the lung findings suggest? Why does she have a tender epigastrium?

6 What is the cause of her shock?
What tests can you do to help with your diagnosis?

7 How would you resuscitate her?

8 Case Senario 2 24 year old Vietnamese lady, factory worker, came to A+E with 2 days history of abdominal pain, worsening in nature. Language barrier, minimal history.

9 On examination: In pain, restless, obey command, moving all 4 limbs.
Pale, no jaundice, dry BP: 90/60mmHg PR: 123bpm (feeble) SpO2: 100% room air RR: 36 breath/min Afebrile CVS, lungs: NAD PA: guarded, tender. No hepatosplenomegaly. Bowel sounds present and normal.

10 What is the diagnosis? Why is her pulse feeble? Why is she dry? How would you manage her?

11 Senario 3: 55 year old gentleman, a case of diabetes mellitus, hypertension, dyslipidemia, on treatment. Under OPD follow up. C/O: Sudden left sided chest pain since morning, associated with SOB, vomiting, profuse sweating. On examination: Conscious, alert, in pain BP: 90/60bpm, PR: 110bpm (regular, poor volume), afebrile, SpO2: 96% under room air, RR: 28breaths/ min

12 Hydration: fair CVS: S1S2 ESM mitral area Lungs: clear, air entry equal PA: soft, non tender, BS present Diagnosis? Explain the murmur? What is the one investigation to order immediately?

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14 What is the diagnosis? How would you manage him?

15 So how do you classify shock?
How do you tell them apart?


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