St. John's University 

PHR 

PHR MISC

Shock & Emergency Case :

Chief Complaint

"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."

HPI

Four days PTA, Mr. Hobbs, a 20-year-old college student, had abdominal pain that he attributed to a flare-up in his Crohn's 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's 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 because he was hypotensive.

PMH

• Crohn disease, diagnosed 4 years ago

FH: Noncontributory

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

Meds

• Infliximab 300 mg by IV infusion over 3 hours every 8 weeks (for Crohn's disease)
• Azathioprine 100 mg PO daily (for Crohn's disease)
• Fish oil (unknown strength) one capsule PO BID
• Multivitamin one tablet PO daily
• Whey shakes for protein supplementation, one shake PO daily

All: NKDA

ROS

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 pain or cramping.

Physical Examination

Gen: Thin, somewhat anxious man in mild distress

VS: BP 84/58 (baseline 122/78), but possible orthostatic changes not determined, HR 132 (baseline 80), RR 16, T 38.2°C; admission Wt 60 kg, Ht 5′10″

Skin: Pale color (including nail beds) and dry, but not cyanotic; no lesions

HEENT: Normal scalp/skull; conjunctivae pale and dry with clear sclerae; PERRLA, dry oral mucosa; remainder of ophthalmologic exam not performed

Neck/Lymph Nodes: Supple, no lymphadenopathy or thyromegaly

Lungs/Thorax: Clear by palpation and auscultation

CV: RRR; S1 and S2 normal; apical pulse difficult to palpate; no MRG

Abd: Perigastric pain on light palpation, no hepatosplenomegaly or masses; bowel sounds present

Genit/Rect: Normal male genitalia; prostate smooth, not enlarged; no hemorrhoids noted; stool heme (-)

MS/Ext: No deformities with normal ROM of joints; no edema, ulcers, or tenderness

Neuro: Mild muscular atrophy with weak grip strength; CN II-XII intact; 2+ reflexes throughout; Babinski downgoing.

Labs

Na 149 mEq/L Hgb 11.9 g/dL Phos 2.9 mg/dL

K 3.3 mEq/L Hct 34.3% AST 35 IU/L

Cl 112 mEq/L Plt 151 × 103/mm3 ALT 23 IU/L

CO2 30 mEq/L WBC 13 × 103/mm3 T. bili 1.1 mg/dL

BUN 32 mg/dL PT 12.1 s Alk phos 83 IU/L

SCr 1.4 mg/dL aPTT 33 s CRP 16 mg/dL

Glu 105 mg/dL Albumin 3.3 g/dL ESR 48 mm/hour

Baseline SCr 1.1 mg/dL.

Other Test Results

CXR negative. In/Out 1200ml/75ml (urinary catheter) for first 3 hours of hospitalization. Results pending for ABG with lactate level, blood and urine cultures, gastroenteric pathogens on stool culture, O & P, and Clostridioides difficile titer.

Assessment

Volume depletion 2/2 Crohn's flare, possible acid-base disorder, possible infectious process, malnutrition, anemia.

CLINICAL COURSE

The patient's clinical condition deteriorated shortly after presentation to the ED, at which time he was subsequently intubated for respiratory failure. The patient was noted to have multifocal PVCs with a disorganized rhythm on the monitor and no pulse was detected. A code was called. Epinephrine, vasopressin, and amiodarone were prepared for administration.

7-Pharmacology: Compare and contrast the mechanism of action of epinephrine and vasopressin.

8-Medicinal chemistry: What are the key functional groups for epinephrine to bind to its receptor? What are the specific intermolecular interactions of each functional group with specific amino acids in the receptor?