Infection Septic Spectrum – © MedTx, LLC 2017

CC: Infection
(Instructions: click on the checkbox to expand the decision tree and suggested options below. Click on the submit button a chart will be generated below in the text box). *Has yet to be sufficiently peer reviewed for clinical purposes.
  • CC: year old with pertinent PMH/PSH presents with
  • presents with chief compliant of
    • Infection
    • Sepsis
    • Hypotension
    • AMS
    • Rash
    • Cough
    • Fever
    • Dysuria
    • Nausea/Vomiting
  • Hx:
    • Upon interview of patient regarding the following potentially infectious symptoms, the pt:
      • fevers,
      •   headache,
      •   neck stiffness,
      •  cough,
      •   SOB,
      •   chest pain,
      •   abdominal pain,
        • in RUQ
        • in RLQ
        • in LUQ
        • in LLQ
        • diffusely
      •  nausea/vomiting,
      •   diarrhea,
      •   rash,
      •  female specific complaints:
        •  vaginal discharge,
        •  hx of STI,
        •  high risk sexual risk behavior,
        •  pelvic pain,
      •  male specific complaints:
        •  testicular pain,
        •  penial discharge,
        •  epidemial pain,
        •  hx of STI,
        •  lesions in groin,
    • Hx regarding immunosuppression:
      • Pt denies any knowledge of immunosuppression.
      • Unknown HIV
      • States no HIV
      • HIV +
        • Last CD4
        • On HAART
      • Malignancy
        • Known malignancy
        • No known malignancy
        • On chemo
          • last chemo
        • Not on chemo
      • IVDU
      • frequent etoh use
      • Hx of TB
      • chronic steroid use
  • REVIEW OF SYSTEMS:
    • Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?
    • Constitutional:
      •  
      • fevers, 
      • rigors, 
    • ENT: 
      • rhinorrhea,  otalgia, sore throat
      • as noted in HPI
    • Eye:
      • vision grossly intact
      • as noted in HPI
    • Cardiac:
      • chest pain, 
      • LE swelling, 
      • no unilateral LE swelling
      • as noted in HPI
    • Pulmonary:
      • shortness of breath, 
      • cough, 
      • as noted in HPI
    • GI:
      • abdominal pain, 
      • nausea, 
      • vomiting, 
      •   BRBPR, dark tarry stool, 
      • diarrhea
      • as noted in HPI
    • GU:
      • no dysuria,
      • no discharge, 
        •  male specific:
          • no testicular pain, 
        • female specific: 
          • no abnormal vaginal bleeding, 
      • as noted in HPI
    • Neuro:
      • no recent severe headache outside of normal headaches per patient, 
      • no recent ALOC, 
      • moves all 4 extremities without any clear focal deficits,
      • Focused Neurological Exam:
        • CN II-XII intact,
        • vision grossly intact, 
        • PEERL, 
        • EOM intact, 
        • strength symmetric intact at major flexion and extension joints throughout UEs and LEs, 
        • no sensory deficits (per patient with light touch),
        • cerebellar function intact (finger-nose-finger), 
        • normal gait in ED,
        • no sensory deficit in GU region, 
        • able to squeeze buttock, 
        • normal rectal tone, 
      • as noted in HPI
    • MSK:
      • no recent trauma
      • no focal weakness, 
      • no pain in extremities or joints, 
      • as noted in HPI
    • Pysch:
      • normal speech, 
      • normal affect,
      • linear though process, 
      • no SI, 
      • no HI, 
      • appears able to care for self by evidence of being dressed, groomed, linear though processes expressed for history and plan after discharge, 
      • no AH, 
      • no VH, 
      • as noted in HPI
    • ID:
      • no recent antibiotics,
    • Endo:
      • no polyuria/polydipsia
      • as noted in HPI
  • PMH/PSH/PSFH:
    • PMH/PSH:   
      • medical/surgical history pertinent to chief complaint as noted in HPI
    • SH: 
      • domiciled, 
      • tob, 
      • etoh use,
        • .    
        • Pt advised not to drink/drive/use concurrent sedating meds/drugs/etoh.
      • illicit drug use,
        • specifically
        • Pt advised not to drink/drive/use concurrent meds/drugs/etoh and offered cessation resources. 
    • FH: 
      • review and non-contributory to patient"s presenting complaint. 
  • EXAM:
    • VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-assess patient):
      • HR:
        • normal HR.
        • tachyardic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD).
          • hypotensive.
      • O2 sat:
        • no hypoxia
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • PHYSICAL EXAM:
      • General:
        • well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe distress
      • HEENT:
        • vision grossly intact.
        • hearing grossly intact.
      • Cardiovascular:
        • no r/m/g
        • no LE swelling
      • Pulmonary:
        • Lungs CBTA,
        • No respiratory distress,
        • Speaking comfortably in full sentences.
        • I/E wheezing,
        • rales,
        • rhonchi
        • respiratory distress,
      • GI:
        • abd soft,
        • abd non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ
        • TTP in RLQ
      • Neuro:
        • Normal LOC.
        • No grossly focal neurological deficits.
        • Somnolent through protecting airway
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory.
      • Psych:
        • Normal speech.
        • Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
  • ———————————————————————–
  • Exam (Complaint relevant additional components of the exam)
  • ED Course:
    • Septic work up and treatment initiated given suspected infectious source and meeting SIRS criteria.
    • Not suspected to be septic. I appreciate vital sign abnormalities meeting SIRS criteria however given high sensitivity/low specificity of SIRS and in my medical opinion after evaluating this patient, I do not believe this patient to be septic and therefore empiric septic work up and treatment risks outweigh the benefits at this time.  Will continue to monitor.
  • Diagnostically:
    • Point of Care Testing:
      • Pregnancy Test:
        • upreg negative,
        • HCG sent,
      • POC gluc:
        • wnl,
      • POC Hg:
        • wnl,
      • iStat:
        • no base deficit,
      • lactate:
        • wnl,
    • Laboratory Analysis Initiated:
      • Standard septic work up labs sent:
        • cbc, bmp, LFTs, lipase, UA, lactate,
        • VBG,
        • ESR,
        • CRP,
        • Cultures: BCxs, UCx,
        • Given pt is sick, will broaden to include
          • DIC labs: coags, fibrinogen, FDP, d-dimer,
          • type/screen to prepare for potential transfusion,
        • Deferred additional labs given well-appearing, non-severe morbid, and not suspected to have sepsis.
        • LP performed given c/f meningitis/encephalitis
        • LP deferred given alternative source and while pt may be encephalopathic, does not appear to have encephalitis.
        • EKG/trop to eval for demand ischemia,
        •  Imaging
          • CXR to eval for pulmonary source
          • CT head to eval for intrcranial infectious process
          • CT chest to eval for intr-thoracic infectious process
          • CT a/p to eval for intra-abd infectious source
          • CT soft tissue at suspect source site
          • XRs directed at suspected infectious source.  Appreciated limited sensitivity of plain films for free air, osteo however low risk and potential diagnostic benefit.
    • Interpretation (subsequent). Diagnostics reviewed and interpreted by me).
      • Complete Laboratory Analysis:
        • CBC:
          • leukocytosis
          • no leukocytosis
          • No significant unexpected anemia suggestive of hemorrhage.
        • BMP:
          • No significant pathologic electrolyte derangements.
          • Appears dehydrated by pre-renal ratio of BUN/Cr
        • LFTs/lipase:
          • No laboratory evidence of hepato-biliary injury (appreciated limited sensitivity of sole and therefore taken into consideration with full clinical picture).
        • ESR
        • CRP
        •  UA:
          • Not c/w infection.
          • Equivocal for infection,
            • will empirically treat.
            • will defer treatment given symptoms and UA does not meet our criteria for urinary source.
            • UCx sent.
          • C/w urinary infectious source
            • Empirically treated
              • ceftriaxone 1 g IV
              • gentamicin for bactericidal concurrence
        • lactate
          • wnl (<2.0)
          • mod elevated (2-4)
          • severely elevated (>4)
    •   CXR:
      • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
      •  Abnormal CXR:
        • Pulmonary edema,
        •  Cardiomegaly,
        •  lobar opacity,
        • diffuse radio-opacities
        • pneumothorax
          • on right
          • on left
          • mediastenium midline
      • Comparison to prior:
        • grossly unchanged, 
        • worsened, 
        • improved, 
      • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads, changes, critical reads).
    •  EKG (as interpreted by prelim ED):
      • Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
      • Rate
        • normal,
        • bradycardic,
        • tachycardic,
      • ST-segment morphology:
        • TWaves:
          • No abnormal TWI,
          • Abnormal TWI,
          • Non-specific repolarization abnormalities,
          • No ST depression, ST depression,
          • No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,
      • Comparison to prior:
        • Unchanged when compared to prior,
        • Attempted but no old EKG available for comparison,
        • ,
      • Summary to pt"s clinical condition:
        • Normal EKG - not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities - no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia.
      • Rhythm: 
        • Regularly regular: 
          • NSR,
          • Sinus tachycardia,
          • Sinus bradycardia,
        • Irregularly irregular:
          • Atrial fibrillation with normal ventricular rate,
          • Atrial fibrillation with RVR,
        • Regularly irregular:
          • tachycardic,
            • Atrial flutter with RVR,
          • bradycardic,
            • Heart block,
              • Type: ,
      • Intervals:
        • Narrow QRS,
          • supraventricular:
            • irregular:
              • AVRT (considering pre-excitation, considering WPW, etc), 
                • Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min. 
                • Tx: Synchronized cardioversion.
                  • Per ACLS 120-200J.
            •  regular: 
              • AVNRT (considering supraventricular tachycardia), 
                • Tx: Adenosine 6mg IV push,
                  • Refractory, therefore second dose 12mg IV push 
                • Synchronized cardioverson.
                  • 100 J
                  • per ACLS for narrow regular 50-100J
        • Wide QRS,
          •  bradycardic:
            •  low junctional escape/ventricular origin,
          • tachycardic:
            •  regular:
              •  stable,
                •  Amiodarone 150mg IV / 10 min
                  •  Refractory, repeated PRN recurrence of VT. 
                  •  Maintenance 1mg/min x 6 hrs.
                •  Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min. 
                • synchronized cardioversion
                  •  100 J (per ACLS)
              •  unstable:
                •  with pulse. Therefore Unstable Ventricular Tachycardia with Pulse. 
                  •  Synchronized cardioversion (per ACLS 100J).
              •  pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.)
  • Medical Decision Making of Severity of Disease:
  • Suspected infectious etiology.
    • Does not meet SIRS criteria, well appearing, therefore not c/w sepsis.
    • Meets SIRS criteria (>=2) though not criteria for severe sepsis given
      • wbc:
        • <4,
        • >12,
        • >10% bands,
      • T:
        • < 36 C (96.8F),
        • > 38 C (100.4F),
      • HR:
        • >90,
      • RR:
        • >22,
        • PaCO2 < 30,
    • Meets criteria for severe sepsis but not septic shock:
      • SBP <90 s/p 2L IVF,
      • lactate >4,
      • Signs of end organ damage:
        • AMS,
        • renal failure,
        • hyperglycemia (in pt not DM),
    • Meets criteria for septic shock:
      • requirement for vasopressors,
    • I appreciate infectious etiology however not suspected to be septic.
    • Not consistent with infectious etiology.
  • Suspect (most consistent with the following ED DIAGNOSIS):
    • DDx includes but is not limited to: Considered the following diagnoses though based upon the medical evaluation, pt does not meet reasonable likelihood for further pursuit at this time (risks/outweigh benefits of non-indicated testing). Attempted shared decision making with discussion with patient to the extent that was possible.
      • meningitis/encephalitis,
      • HEENT infection,
      • PNA,
      • cholecystitis,
      • appendicitis,
      • intra-abdominal abscess,
      • cellulitis,
      • NSTI,
      • UTI,
      • pyelonephritis,
      • male specific pathologies
        • prostatitis
        • orchitis
      • female pathologies
        • PID
        • TOA
      • osteomyelitis,
      • endocarditis,
  • Therapeutically:
    • IVF 30cc/kg initiated as promptly as logistically possible
    • Additional IVF based upon repeat eval of volume status to optimize risk/benefit of precipitating volume overload v. completion of resuscitation.
    • Early goal directed antibiotics
      • cefepime 1g IV / Vancomycin 15-20 mg/kg IV
      • piperacillin/tazobactam (Zosyn) 3.375 g IV / Vancomycin 15-20 mg/kg IV
    • H/H > 10/30, transfuse PRN
    • MAP goal 65
      • Does not require pressors at this time.
      • norepinephrine required, initiated.
        • ((first line pressor))
        • ((range 2-20mcg/min))
      • epinephrine required, initiated.
        • ((second line pressor))
        • ((range 1 – 20 mcg/min)))
      • vasopressor required, initiated
        • ((third line pressor))
        • ((usual dose 0.4u / min))
      • Access:
        • Pressors run peripherally as is considered safe for a finite duration. To be switched to central access if pressor requirement persists.
        • Central access obtained given anticipated prolonged dependence on pressors.
    • Intubation
      • not indicated at this time given pt is maintaining airway
      • required performed to reduce cardiac demand, and pt is not protecting airway.
  • Re-evaluation:
    • Perfusion Reassessment for Septic Shock:
      • Exam:
        • vitals signs assessed
        • Heart exam:
          • tachycardic
          • normal rate
        • Lung exam:
          • does not appear to be developing pulm edema
          • suspected developing pulm edema
        • Peripheral pulses
          • strong radial pulse
          • weak peripheral pulses
        • cap refill
          • <2 sec
          • >2 sec
        • skin
          • warm, well perfused
          • cold, clammy
        • Fluid Eval
          • Bedside US IVC
            • Appears vol down
              • not >50% collapsable w/ resp variation
              • >50% collapsable w/ resp variation
            • Will attempt fluid challenge and monitor for response
        • On re-evaluation, remains hemodynamically stable. Will continue observation, treatment.
  • Disposition:
    • Discharged from Emergent Department with prompt PMD follow up.
      • In sum, on re-eval, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new develop of new infectious symptoms.  Remains hemodynamically stable. Is not sufficiently comorbid to preclude discharge.  Pt wishes for discharge, will oblige.
      • The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an traumatic illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate call or follow up with their primary physician or return to this or any ED for reevaluation. More extensive discharge instructions were given in the patient’s discharge paperwork.  Discharge Instructions included: Follow Up: Patient/family advised for prompt follow up with primary care physician. I explained the importance of follow up given the limitations of a one time emergency department visit and the importance of continued care and diagnoses that may only be elucidated by serial evaluations. Should the patient have difficulty finding primary care follow up, the patient was advised of community health resources as well as advised that they always could return to the Emergency Department for re-evaluation. Return precautions – both general and specific to the patient’s evaluation were discussed with the patient.
    • Placed on observation for parental antibiotics, observation.
    • Admitted given above findings/rationale
  • Counseling: Patient/family was counseled on the above evaluation, findings, assessment, and plan and were in agreement with plan. All questions answers. Reiterated understanding.
  • Supplemental Aspects of Care
    • SW offered to patient
    • Critical Care:
      • Critical Care Procedure Note:
      • Performed by attending physician
      • Approximate time of critical care:
          • Critical care procedure note. Performed by attending physician. Total critical care time approximately
            • 37 minutes
          • The patient required critical care given the patient’s presentation predispose the patient to significant pathology which could result in loss of life program and permanent morbidity. Emergent diagnostics and treatments were of critical important to elucidate, life-threatening pathologies and mitigate risk of imminent deteriorated. The patient required my direct emergent evaluation in obtaining a history, performing exam, interpreting vital signs including pulse oximetry, ordering and interpretation of diagnostic studies, coordinating plan , ordering emergent interventions and repeated reevaluations in order to evaluate response to the above interventions.  This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
        • Observation Note
          • Given patient’s presentation with trauma, the patient required an observation in the ED to evaluate for potential improvement, ensure stability, or deterioration given that traumatic injuries can have delayed manifestation of symptomatology and without observation present too high of a risk and precludes safe discharge without said observation.  As such, the patient was observed in the ED on telemetric monitoring with re-evaluation of vital signs and by RN as well as more extensive re-evaluations by me.
          • Observation time began at:
          • Observation time ended at:
          • Total observation time:

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