Case history
Case history #1
A 72-year-old man presents with progressive malaise, weakness, and confusion. He suffers from hypertension but this is well controlled with a thiazide diuretic and an ACE inhibitor. He has diabetes, treated with metformin, but no other medical problems, and he is able to perform all activities of daily living independently. The patient's wife reports general deterioration over the last 2 days. The patient appears severely ill, weak, and obtunded, and is unable to speak. His skin is mottled and dry with cool peripheries, and he is mildly cyanotic. Respiratory rate is 24 breaths/minute, pulse rate 94 beats/minute, blood pressure 87/64 mmHg, and temperature 95.9°F (35.5°C). Auscultation yields coarse crackles over both lung bases.
Case history #2
A 45-year-old man presents to the emergency department with upper abdominal pain and a history of peptic ulcer disease. He reports vomiting blood at home. He is otherwise well, takes no medications, and abstains from use of alcohol. While in the emergency department he vomits bright red blood into a bedside basin and becomes light-headed. Blood pressure is 86/40 mmHg, pulse 120 bpm, and respiratory rate 24 per minute. His skin is cool to touch, and his skin is pale and mottled.
Other presentations
Presentation of shock depends on the etiology but will usually be recognized by hypotension, decreased urine output, and clouding of consciousness. A compensatory tachycardia may or may not be present. Hemorrhagic shock (a form of hypovolemic shock) can occur from trauma, after surgery (drain losses may be an indication), as hematemesis, or from rectal bleeding. This can occur rapidly. Other forms of hypovolemic shock can result from third space losses in pancreatitis, diarrhea, and vomiting, extensive burns, or concealed hemorrhage, such as in abdominal aortic aneurysm rupture. Obstructive shock may present suddenly with cyanosis and respiratory distress with a tension pneumothorax, or the triad of muffled heart sounds, low blood pressure, and jugular venous distention as classically seen in cardiac tamponade. Septic shock is typically described as hypotension with increased cardiac output and warm peripheries due to peripheral vasodilation and with a suspected source of infection. The patient is often febrile. Cardiogenic shock may follow myocardial infarction, cardiomyopathy, or fulminant heart failure.[4]
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