SIRS – MedTx

  • Chief compliant:
    • Presents today with SIRS criteria and infectious symptoms.
  • Hx:
    • Regarding potential source, the patient endorses/denies the following symptoms:
    • Systemically:
    • Denies fevers
    • Endorses rigors
    • Denies history of known immunosuppression (specifically denies chronic steroid arrhythmia no suppressants, denies known HIV positive status)
    • Respiratory symptoms:
    • Endorses shortness of breath
    • Endorses dyspnea on exertion
    • Endorses productive cough with colored phlegm.
    • Has history of smoking.
    • GI symptoms:
    • Denies abdominal pain
    • Denies nausea or vomiting
    • Denies diarrhea
    • Genitourinary symptoms:
    • Denies dysuria
    • Denies polyuria
    • HEENT symptoms:
    • Denies rhinorrhea
    • Denies otalgia
    • Denies sore throat
    • Skin symptoms:
    • Denies rash or any new dermatologic lesions.
    • Occupational:
    • Denies any recent travel
    • Denies sick contacts
    • Is considered healthcare associated
  • ROS:
    • *10 Point Review of System negative unless otherwise specified in the HPI
    • Constitutional: no lethargy
    • Eyes: no recent changes in vision
    • Nose/Mouth/Throat: no sore throat, rhinorrhea, otalgia
    • Cardiovascular: no chest pain, no palpitations
    • Respiratory: no SOB, no new cough
    • Gastrointestinal: no n/v/d. no BRBPR/melana
    • Genitourinary: no dysuria
    • MSK: no trauma to extremities
    • Neurological: no confusion
    • Psychiatric: no disorganized thinking
  • PSFH:
    • PMH/PSH:
      • Reviewed, pertinents as noted in HPI.
    •  SH:
      • Denies tob/etoh/illicits
      • Endorses tob.     Denies etoh/illicits
      • Endorses etoh.   Denies tob/illicits
      • Endorses tob/etoh/illicits
    • FH:
      • Reviewed and non-contributory to patient’s chief complaint.
  • Exam (Complaint relevant additional components of the exam)
    • *8 System Physical Exam:
    • Constitutional:
      • mild distress, appears stated age
      • moderate distress, appears stated age
      • severe distress, appears stated age
    • HEENT: vision grossly intact, EOM intact
    • CardioVascular: RRR, No r/m/g
    • Pulmonary: non-labored breathing, no rhonchi, no rales
    • Abdomen: soft, non-tender
    • Extremities: no edema, no deformities
    • Neurologically: normal speech, no focal deficits
    • Psychiatrically: cooperative, linear
    • Skin: no rashes, warm and dry
  • ED Course:
    • DDx:
      • SIRS, sepsis, viral syndrome, bacteremia, pneumonia, intra-abdominal infection, urinary tract infection, cellulitis,
    •  Diagnostically:
      • Interpretation of Pulse Oximetry:
        • No evidence of hypoxia on pulse oximetry in emergency department
      • Laboratory Results Reviewed. Analysis/Interpretation:
        • Pregnancy Test
          • negative
          • _
        • Basic Labs:
          • CBC:
            • No significant luekocytosis/neutropenia, no unexpected anemia, no thrombocytopenia.
            • Mild leukocytosis suggestive of infectious process
          • BMP:
            • No significant pathologic electrolyte derangements.
          • Basic laboratory analyses does not suggest more pathologic process in patient at this time.
        • Complete Laboratory Analysis:
          • CBC:
            • No luekocytosis, no unexpected anemia, no thrombocytopenia.
            • Mild luekocytosis suggestive of infectious process.
          • BMP:
            • No significant pathologic electrolyte derangements.
          • LFTs/lipase:
            • No laboratory evidence of hepato-biliiary pathology.
          • UA:
            • No consistent with urinary tract infection
              • in conjunction with clinical context.
      • EKG Interpretation:
        • Normal EKG (Indication: eval for ischemia):
          • EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.
          • Interpretation: No clear evidence of active ischemia on EKG
        • Normal EKG (Eval for arrhythmia/syncope):
          • EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.
          • Interpretation: No cardiogenic etiology for syncope obvious on EKG.
        • Sinus tachycardia, no abnormal TWI, no significant ST elevation/depression
        • Non-specific repolarization abnormalities. No ST elevation/depression.
        • Evidence of previous or active myocardial ischemia by abnormal TWI. NSR.
        • Evidence of previous myocardial ischemia by pathologic Q waves.
        • ST elevation concerning for active myocardial ischemia/infarct.
      • Radiograph Interpretation:
        • CXR
          • Normal CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Cardiomegaly. Otherwise non-remarkable CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema.. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Pulmonary edema. Evidenced radio-opacities consistent with fluid in pulmonary parachyma.
          • Pneumonia. Evidenced by consolidation concerning for pneumonia.
          • Non-specific diffuse opacities. Concerning for diffuse infectious process verses pulmonary edema.
          • Not indicated. Given patient is not comorbid, not other extremes of age, there are no abnormal vital signs-specifically no tachycardia, no tachypnea, no fever, and the pulmonary exam is unremarkable, bacterial pneumonia is sufficiently unlikely that a chest radiograph is not indicated at this time. Patient was advised to return precautions in case of subsequent development of superimposed bacterial infection.
        • lactate, blood cultures
  • Medical Decision Making:
    • Diagnostically
    • Broad workup initiated order to search for potential bacterial source of his abnormal vital/laboratory findings including CBC, BMP, LFTs, lipase, urinary analysis, chest x-ray, lactate, and urine and blood cultures.
    • Therapeutically
    • Patient resuscitated with 30 cc/kg of intravenous fluids.
    • Initiated empiric broad-spectrum antibiotics based upon suspected source as promptly as was possible given time of presentation and remaining of patient and results of diagnostics.
    • Severity of Infection:
    • Meet criteria for severe sepsis by evidence of lactate greater than 4.
    • Hemodynamically is guarded but stable, will continue with the above stated plan given patient appears to be clinically overall improving.
    • Based upon the above evaluation, suspect that there is a sufficiently high likelihood for a bacterial infection and as such patient requires observation versus admission status in order to continue monitoring of hemodynamics, monitor for potential requirement of additional intravenous fluids and continuation of IV antibiotics.
    • Considered other etiologies specifically CHF or ACS and as such EKG, troponin and BMP ordered. Unlikely at this time given history is atypical for cardiac etiology
  • Re-evaluation:
    • on reevaluation of patient by me, patient has improvement in vital signs, good capillary refill and pulmonary exam without significant rails. Therefore suspect that patient is improving with the above stated resuscitation of severe sepsis. We will send repeat lactate after resuscitation.
  • Diagnosis:
    • Sepsis
    • Severe sepsis
  • Disposition:
    • Discharged from Emergent Department with prompt PMD follow up
      • Discharge Instructions: 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 status given above rationale
    • Admitted given above rationale
    • Counseling: Patient/family was counseled on the above evaluation, findings, assessment, and plan. All questions were answers. Verbal expression by patient/family provided of understanding.
  • Billing
    • Given patient had initial vital sign abnormalities that patient was at risk of significant deterioration resulting in significant morbidity or potential mortality, patient required direct observation and monitoring in the emergency department with emergent diagnostics, emergent interventions and assessment as well as multiple re-evaluations in order to ensure that patient would be appropriately and emergently evaluated and treated.
    • Critical Care
      • Critical care procedure note:
      • Authorized and performed by: Attending physician
      • Total critical time:
        • 35 minutes
      • Due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. The critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient’s presentation to develop treatment plan and implement the requisite steps. In addition given attentional for deterioration with morbidity mortality, or failure for spots to treatment, the patient required multiple reassessments.
      • indication for critical care including risk factors of
        • Hypotension, shock, hypoxia, dysrhythmia, acidosis
      •  potential impending deterioration included
        • Airway, respiratory, cardiovascular, CNS, metabolic, renal or hepatic deterioration
      • This critical care time is separate from teaching or other separately billable procedures or treating other patients.