BACKGROUND

• An 84-year-old female is brought in by family with complaints of increased confusion and lethargy.
• Patient usually lives alone and is fully functional.
• Son reports that she has been increasingly confused and sleeping a lot at home.
• Son denies any fever.
• Patient complains of pain “all over” and responds to repeated questions with “I think I’m sick”

VITAL SIGNS

• BP 105/64, HR 115, RR 24, T 96°F, SpO2 92% Room Air
• Patient is alert, and oriented to person but thinks is it 1990
• PMH: HTN: Metoprolol
• DM: Insulin
• Other meds: ASA, Calcium

RESULTS OF DECISION POINT ONE

12 lead EKG, CBC, CMP, urinalysis, Chest x-ray

Initial 12 lead EKG to assess myocardial function

CBC to assess WBC and potential anemia

BMP to assess electrolyte disturbance and potential for DKA

Urinalysis to assess for potential infection

Chest x-ray to assess for potential infection

RESULTS OF INDICATED TESTS

Complete Blood Count (CBC)

WBC 3.4 k/UL

Hgb 9.3 g/dL

Hct 28%

Platelets 250 k/UL

Differential

Neutrolphil 90%

Bands 10%

Eosinophil 0%

Basophil 0%

Lymphocyte 2%

Monocyte 3%

Basic Metabolic Profile (BMP)

Na+ 132mEq/L

K+ 3.7mEq/L

HCO3 27mEq/L

Cl- 101mEq/L

Glucose 1766 mg/dL

BUN 55 mg/dL

Creatinine 2.0 mg/dL

Urinalysis (U/A)

Color Yellow: Clarity Dark/Cloudy

Sp gravity 1.042

pH 6.2

Total Protein negative

Glucose positive

Ketone negative

Bilirubin negative

Hematuria positive

Leuk. Est. +++

Nitrite +++

RESULTS OF DECISION POINT TWO:

• Urinalysis shows hematuria, positive nitrate, positive leukocyte esterase which all are indicative of a UTI.
• Elderly frequently have a low WBC and low body temperature in the presence infection.
• Chest x-ray is clear and EKG shows tachycardia but no arrhymia or myocardial hyposia.
• The patient remains confused and is becoming more lethargic. Follow up BP is 82/42. Serum lactate level is 4.5. What is your diagnosis now?

Septic shock

SIRS (systemic inflammatory response syndrome) require the presence of two of the four factors:

• Temperature less than 36.0 C or greater than 38.0 C
• Heart rate greater than 90 BPM
• Respiratory rate > 24 breaths per minute or PaCO2 < 32
• WBC less than 4,000 or greater than 12,000; or Bandemia>10%