Medical discussion with the senior doctor

The ongoing issues with perfusion for continue. Her BP remains low despite multiple fluid challenges indicating a low tissue perfusion and the potential for organ dysfunction to develop. Together with an increased lactate level and the suggestion of an underlying infection, she is potentially developing sepsis. The impression, in this case, is 'high (red) risk' of sepsis.

Medical history

The junior doctor completes the medical history mainly from 's daughter and a physical examination of , noting the extent of her leg oedema (legs are no more oedematous or redder than usual) and her abdomen is soft and non-tender. She identifies that she wants to check with the registrar in developing a plan of care.

Risk of sepsis

Based on the NICE guidelines (2016), now has the following criteria:

High (red) risk	Lactate level is now 3.5 mmol/L following latest repeat blood gas
High (red) risk	Tachypnoea ≥ 25 bpm
High (red) risk	FiO₂ > 0.4 or > 40% oxygen required to maintain SaO₂ > 92% or 88% in known COPD
High (red) risk	SBP ≤ 90 mmHg or ≥ 40 mmHg below normal for patient
Moderate (amber) risk	Tachycardia 91-130 bpm

Fluid status

The ward nurse starts to continuously monitor 's ECG and take blood pressure recordings every 30 minutes. The lactate level is now 3.5 mmol/L. Further crystalloid fluids are commenced to go over the next 30 minutes.

Infection screening

The doctor reviews 's x-ray and requests a urine sample to assess the urine for pnemococcal and/or legionella organisms. The ward urinalysis result is NAD. Her oedematous legs are no redder than is usual for and her chest x-ray shows a white patch in the right lung, suggesting consolidation and pneumonia.

Antimicrobial review

In light of new evidence on the chest x-ray of a community acquired pneumonia and a normal urinalysis, Tazocin is stopped promptly and intravenous antibiotics are changed to a combination of co-amoxiclav and clarithromycin*. Appropriate specimens need to be taken to aid with diagnosis of the infecting organism/pathogen e.g. viral throat swab, sputum specimen and urinary antigens for pneumoccocal and/or legionella organisms.

NB: *Always check your local guidelines/protocols to ensure locally recommended medicines are prescribed.

Transfer to HDU

It is suggested that is transferred to the High Dependency Unit (HDU) for more invasive, continuous monitoring. A bed is available.

Observations Medicines Fluid Balance Blood Results

MEDICINE PRESCRIPTION AND ADMINISTRATION RECORD
WARD Emergency Dept. WARD __________ WARD __________			CONSULTANT ____________________		DATE OF ADMISSION		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
Card No 1 of 1		Chart rewritten By _____________ Date ________________________ Pharmacy check By _____________ Date ________________________			Weight _______(kg) Date ____________ Weight _______(kg) Date		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
DRUG ALLERGY or ADVERSE EFFECT Medicine/Other Signature				If none know tick box [✔] Effect Date This section must be completed and signed by a prescriber or Pharmacist
ONCE ONLY MEDICINES
Date	Medicine	Dose	Route	Administration Instructions	Time Required	Prescriber's Sig, Print Name & Bleep	Time Given	Given By	Checked By	Pharm
	Tazocin	4.5g	I.V.	Give Immediately	18.00	A.BRN 1234	18.15	JE	AM
	Salbutamol	2.5mg	neb		18.00	A.BRN 1234	18.15	JE	AM
	Atrovent	500mg	neb		18.00	A.BRN 1234	18.15	JE	AM

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART DATE: WARD: Emergency Dept.
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00
...
18:00	500					++ incontinent
19:00	500	30 (tazocin)		1030	1030				+ve 1030
20:00	500, 500			1000	2030				+ve 2030
21:00
22:00
23:00
24:00

Patient Details Patient Name: Age: Hospital Number:				FLUID CHART Part One \| Part Two DATE: WARD: Emergency Dept. PREVIOUS DAY'S BALANCE: +ve 2533
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00	250		10	260	260	30	30	30	+ve 230
02:00	250		10	260	520	35	35	65	+ve 455
03:00	250		10	260	780	40	40	105	+ve 675
04:00	250		10	260	1040	15	15	120	+ve 920
05:00	250	500 Hartman's	10	760	1800	25	25	145	+ve 1655
06:00	250		10	260	2060	30	30	175	+ve 1885
07:00	250		10	260	2320	30	30	205	+ve 2115
08:00	250		10	260	2580	20	20	225	+ve 2355
09:00	250		10	260	2840	10	10	235	+ve 2605
...

Haematology and CoagulopathyClinical Chemistry and Liver Function Tests
Test	Normal Values	18:30	20:15	06:00
HB	11.5 - 16.5 g/dL	10.0	9.8
Platelets	150 - 450 x 10^-9/L	120	114
WBC	4.0 - 11.0 x 10^-9/L	14.0	14.8
MCV	84 - 102 fL	85	84
Neutrophils	2.0 - 7.5 x 10^-9/L	9.0	9.2
ESR	1 - 20
APTT Ratio	0.85 - 1.14
INR	0.8 - 1.2
Prothrombin Time	10.0 - 12.0 sec's	12	12
APTT	21.0 - 29.0 sec's	32	32
Thrombin Time	17.0 - 21.0 sec's	21	21
D-Dimer	0 - 250 µg/L	200	202
Fibrinogen	1.8 - 4.0 g/L

Clinical Chemistry and Liver Function TestsHaematology and Coagulopathy
Test	Normal Values	18:30	20:15	06:00
Sodium	134 - 145 mmol/L	140	138
Potassium	3.5 - 5.3 mmol/L	4.5	4.2
Urea	2.9 - 7.5 mmol/L	10.0	10.2
Creatinine	45 - 84 µmol/L	100	104
GFR	(ml/min)
Glucose	4.0 - 8.0 mmol/L	9.9	8.9
Amylase	0 - 110 U/L
CK	25 - 200 U/L
ALT	0 - 35 U/L	30	35
γGT	0 - 40 U/L	50	48
Bilirubin	0 - 21 µmol/L	40	45
Alk Phosphate	40 - 130 U/L	180	183
Albumin	30 - 50 g/L	24	18
CRP	0 - 10 mg/dL	110	121
Troponin	up to 0.1 µg/L
Bicarbonate	24 - 32 mmol/L
Calcium	2.2 - 2.6 mmol/L
Phosphate	0.8 - 1.45 mmol/L
Magnesium	0.7 - 1.0 mmol/L

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