Sepsis

Chief complaint

65-year-old female brought in by family, with shortness of breath, cough, and fever

Vital signs

BP: 78/32 HR: 125 RR: 30 T: 40.2°C Sat: 88% on RA

What does the patient look like?

Patient appears stated age, tachypneic, moderate respiratory distress, somnolent, but awakens
easily.

Primary Survey

a. Airway: speaking in full sentences

b. Breathing: increased respiratory rate, moderate distress, no cyanosis
c. Circulation: warm, increased capillary re ll

Action

a. Oxygen
b. Two large-bore peripheral IV lines
c. Labs
i. CBC, BMP, LFT, coagulation studies, blood type and cross-match
ii. Lactate, blood cultures, UA, urine culture
d. 2 L NS bolus
e. Monitor: BP: 77/40 HR: 112 RR: 26 Sat: 100% on Oxygen
f. EKG
g. CXR

History

HPI: a 45-year-old female with no past medical history here with fever and shortness of breath for
3 days. Patient states symptoms started with a cough for 2 days but since yesterday with fevers
of 40.2°C and chills
Other History Unremarkable

Secondary survey

General: somnolent but arousable, oriented × 3, tachypneic, mild respiratory distress on oxygen
Lungs: crackles bilaterally, no wheezes/rhonchi
Other Unremarkable

Nurse

a. 2 L uids: BP: 110/78 HR: 110 RR: 20 Sat: 97% on Oxygen

b. 1 L uids: BP: 80/68 HR: 120 RR: 24 Sat: 97% on Oxygen
c. No uids BP: 62/48 HR: 130 RR: 28 Sat: 97% on Oxygen

Results
WBC 17, Lactic Acid 4, CRX:Rt lower pneumonia.
Other Labs Normal

Action
IV antibiotics
Consultation include ICU
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 Diagnosis
Community-acquired pneumonia

Critical actions

· IV access
· NS uid bolus > 2 L
· CXR
· Antibiotics
· Admission
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