Chapter 138: Sepsis: Time Is of the Essence Level III

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Compare and contrast the different syndromes related to sepsis (systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock).

• State patient variables used to diagnose sepsis.

• Identify the initial treatment goals for patients after the diagnosis of sepsis.

• Formulate a comprehensive treatment plan for the initial management of patients with sepsis.

• Recommend appropriate supportive care therapies for patients with sepsis.

PATIENT PRESENTATION

Chief Complaint

The patient presents from her nursing home with altered mental status and lethargy that has progressively worsened over the last 24 hours.

HPI

Ruth Carter is an 80-year-old Caucasian female who resides in a nursing home with a past medical history that includes hypertension, dementia, chronic kidney disease, depression, and GERD. She was discharged last week from another hospital after being treated for 5 days for a urinary tract infection. Patient did well through the first two days after discharge, but has become increasingly lethargic and drowsy in the last 24 hours. Patient is barely responsive at the time of assessment. Patient has had no reports of fever, nausea, vomiting, or pain.

PMH

• HTN

• Dementia

• CKD, stage II

• Depression

• GERD

PSH

Non-contributory

FH

No HTN, DM, CAD, cancer, or vascular disease

SH

• Lives in a nursing home due to dementia

• No tobacco, alcohol, or illicit drug use

Medications PTA

• Clonidine 0.2 mg/24 H transdermal patch every week

• Acetaminophen 500 mg PO Q 6 H as needed for pain/fever

• Lorazepam 0.5 mg PO QHS

• Hydralazine 50 mg PO TID

• Omeprazole 20 mg PO QAM

• Rivastigmine 4.6 mg/24 H transdermal patch Q HS

• Levofloxacin 500 mg PO Q 24 H for 3 days (received 5 days of inpatient therapy; completed total course 2 days ago)

Allergies

NKDA

Review of Systems

Unable to obtain due to patient’s mental status

Physical Exam

Gen

Unresponsive, thin appearing female in acute distress

Vital Signs

BP 86/42 mm Hg, P 118–142 bpm, RR 14–35 bpm, T 35.6°C; SpO₂: 94% on 8 L NC, Ht 5′3″, Wt 50.8 kg

Skin

Skin is warm, dry and pink, intact with no rashes or lesions

HEENT

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