Clinical note · #59
Critical care
Patient: Maria Gonzalez · MRN: 54621387 · Admission: 09/26/2024 · Critical care: 09/27/2024 · Attending: Dr. Thomas Monroe
Primary diagnosis: septic shock secondary to urosepsis. Secondary diagnoses: acute kidney injury, metabolic acidosis.
Hospital course
Maria Gonzalez, a 75-year-old female, presented with fever, confusion, and hypotension. Blood cultures revealed Escherichia coli urosepsis. She developed septic shock with multi-organ failure, requiring immediate vasopressor support with norepinephrine to maintain a mean arterial pressure (MAP) of 65 mmHg. A central venous catheter was placed for vasopressor administration and fluid resuscitation. The patient was also started on continuous renal replacement therapy (CRRT) due to acute kidney injury with metabolic acidosis. Time was spent adjusting vasopressor dosages and fluids, monitoring vital signs, and managing metabolic derangements. Total time spent during the critical care was 160 minutes.
Key interventions
- Central venous catheter placement
- Vasopressor support with norepinephrine
- Continuous renal replacement therapy (CRRT)
Condition: critical, with continued need for CRRT and vasopressors. Transferred to ICU for ongoing care.