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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.

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.

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

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.

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.

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.

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

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