[##]-year-old [male/female] with [altered mental status/fever/weakness/etc.]
with history and exam consistent with sepsis from [unclear infectious
source/pneumonia/urinary tract infection (UTI)/etc.].
Patient felt to have symptoms concerning for a potential infection based
on [fever (temperature ≥100.4°F)/elevated heart
rate (>90)/elevated respiratory rate (>20 or PaCO2 < 32
mmHg)] noted at time of initial triage.
Labs were obtained to include a lactate level, CBC, and blood cultures,
and were notable for [leukocytosis (>12,000/mm3)/leukopenia
(<4,000/mm3)/bandemia (>10% bands)] concerning for systemic
inflammatory response (SIRS). The
patient was noted to have an initial lactate that was [within normal
limits/minimally/moderately/significantly elevated].
We considered possible respiratory sources for infection and obtained a
chest x-ray [and additional imaging], which was [notable for
pneumonia/unremarkable]. We considered
possible urinary sources of infection and obtained a urinalysis and urine
culture, which was [notable for findings suggestive of a
UTI/unremarkable]. We considered
possible soft tissue sources for infection [and noted findings on the LOCATION
consistent with cellulitis/abscess/fasciitis].
We considered [additional infectious sources] and obtained [additional
testing] which was [notable for FINDING/noted to be unremarkable].
Based on findings SIRS criteria and [presumed infectious source], the
patient was felt to meet criteria for sepsis.
Broad spectrum antibiotic coverage was initiated within 3 hours of ED
triage with [antibiotics used].
Resuscitation with crystalloids IV [was initiated as a 30 mL/kg bolus/was
initiated as ### mL boluses due to patient’s history of heart failure/etc.]. Vasopressors [were/were not] felt to be
indicated due to [ability/inability] to maintain mean arterial pressure (MAP)
of ≥65
mmHg [after/despite] crystalloid boluses.
The patient was felt to have [no] evidence of septic shock based on
[no/vasopressor requirement to maintain MAP ≥65 mmHg and/or serum lactate >2 mmol/L despite resuscitation with
crystalloids/without evidence of hypovolemia].
Patient noted to have a qSOFA score of [##] suggestive of [<1 patient
who is not high risk for poor outcome/≥2 high risk of poor outcome], so the patient was felt to meet criteria
for admission to [general floor with telemetry/step down unit/ICU]. We discussed presumed diagnosis of
[unknown/infectious source] with findings concerning for sepsis with the [patient/family/caregiver]. We discussed plan for admission for further
treatment, and the [patient/family/caregiver] demonstrated understanding and
agreement with this plan.
We discussed the case with Dr. [Name] who agreed with need for admission
to the [general floor with
telemetry/step down unit/ICU] for further treatment of [infection
and sepsis].
