SIRS/Sepsis/Septic Shock 2/2 ***

#SIRS/Sepsis/Septic Shock 2/2 ***
Checklist
-- ABCs: determine if need ICU for pressors or intubation (often from PNA, ARDS, or hyperventilation from acidosis); do they need central access?
‍-- Chart Check: calculate qSOFA and SIRS;
-- HPI Intake: *** previous infections, recent abx, indewlling lines, sick contacts, immune status
-- Can't Miss: *** shock, poor source control
-- Admission Orders: *** continuous pulse ox and tele, CBC, BMP, LFTs, coags, VBG, lactate, make sure infectious workup sent (2 sets of peripheral BCx, UA, UCx before antibiotics), CXR if not done
-- Initial Treatment to Consider: *** fluid resuscitation - 30cc/lg LR in first few hours, pressor if no longer fluid responsive, decide on ongoing abx,

Assessment:
-- History: *** previous infections, recent abx, indewlling lines, sick contacts, immune status
-- Clinical: *** fever, AMS, localizing symptoms, urine output
-- Exam: *** hypotension, widened pulse pressure, low diastolic pressure, tachycardia, AMS, warm, rigors, diaphoresis, volume assessment, rash, abscess, decrease breath sounds, crackles, RUQ pain, signs of peritonitis, CVA tenderness, joint pain
-- Data: *** WBC, lactate, creatinine, CXR, UA
-- qSOFA:  ***/3 - (RR >22, AMS, systolic BP <100)
-- SIRS: ***/4 - (HR>90, RR>20, WBC <4 or >12, T < 96.8 or > 100.4)
-- Etiology/DDx: *** pulm, urinary, CNS/spine, bloodborne, C Diff

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

Plan:
Workup
-- Labs: *** f/u BCx, UA, UCx, procalcitonin; conisder 1,3 BDG, galactomannan, cryptococcal Ag if c/f fungemia
-- Monitoring: trend daily CBC, CMP, LFTs, Coags; strict I/O’s

Treatment
-- Abx: Empiric treatment with *** (vancomycin PLUS ceftriaxone OR cefepime OR pip/tazo OR carbapenem) to cover for ***; If c/f toxic shock or fournier’s, add clindamycin
-- Volume: s/p ***; plan for *** (goal to bolus at least 30 mL/kg) with *** to assess for response
-- Pressor: *** for MAP goal >65 (levo --> vaso --> epi; phenylephrine for afterload)
-- O2: *** with continuous pulse ox; titrate as needed for goal ***
-- Other: *** (transfusion, dialysis, bicarb, hydrocort)
‍
Presenting: 

The patient remains septic from *** (known/suspected) *** (etiology).
They are currently *** (improving/stable/worsening) based on *** (fevers, hypotension, pressor requirement, WBC, UOP, other end organ-dysfunction, etc).
We are covering for *** with *** (antibiotics)
We have resuscitated the patient with ***, and their current volume status is *** with an ScVO2 of ***.
There *** (is/is not) currenty a pressor requirement ***
We’ve sent *** and are waiting for *** to come back.
Today, I propose we ***
‍
#SIRS/Sepsis/Septic Shock 2/2 ***
Checklist
-- ABCs: determine if need ICU for pressors or intubation (often from PNA, ARDS, or hyperventilation from acidosis); do they need central access?
‍-- Chart Check: calculate qSOFA and SIRS;
-- HPI Intake: *** previous infections, recent abx, indewlling lines, sick contacts, immune status
-- Can't Miss: *** shock, poor source control
-- Admission Orders: *** continuous pulse ox and tele, CBC, BMP, LFTs, coags, VBG, lactate, make sure infectious workup sent (2 sets of peripheral BCx, UA, UCx before antibiotics), CXR if not done
-- Initial Treatment to Consider: *** fluid resuscitation - 30cc/lg LR in first few hours, pressor if no longer fluid responsive, decide on ongoing abx,

Assessment:
-- History: *** previous infections, recent abx, indewlling lines, sick contacts, immune status
-- Clinical: *** fever, AMS, localizing symptoms, urine output
-- Exam: *** hypotension, widened pulse pressure, low diastolic pressure, tachycardia, AMS, warm, rigors, diaphoresis, volume assessment, rash, abscess, decrease breath sounds, crackles, RUQ pain, signs of peritonitis, CVA tenderness, joint pain
-- Data: *** WBC, lactate, creatinine, CXR, UA
-- qSOFA: ***/3 - (RR >22, AMS, systolic BP <100)
-- SIRS: ***/4 - (HR>90, RR>20, WBC <4 or >12, T < 96.8 or > 100.4)
-- Etiology/DDx: *** pulm, urinary, CNS/spine, bloodborne, C Diff

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

Plan:
Workup
-- Labs: *** f/u BCx, UA, UCx, procalcitonin; conisder 1,3 BDG, galactomannan, cryptococcal Ag if c/f fungemia
-- Monitoring: trend daily CBC, CMP, LFTs, Coags; strict I/O’s

Treatment
-- Abx: Empiric treatment with *** (vancomycin PLUS ceftriaxone OR cefepime OR pip/tazo OR carbapenem) to cover for ***; If c/f toxic shock or fournier’s, add clindamycin
-- Volume: s/p ***; plan for *** (goal to bolus at least 30 mL/kg) with *** to assess for response
-- Pressor: *** for MAP goal >65 (levo --> vaso --> epi; phenylephrine for afterload)
-- O2: *** with continuous pulse ox; titrate as needed for goal ***
-- Other: *** (transfusion, dialysis, bicarb, hydrocort)

Presenting:

The patient remains septic from *** (known/suspected) *** (etiology).
They are currently *** (improving/stable/worsening) based on *** (fevers, hypotension, pressor requirement, WBC, UOP, other end organ-dysfunction, etc).
We are covering for *** with *** (antibiotics)
We have resuscitated the patient with ***, and their current volume status is *** with an ScVO2 of ***.
There *** (is/is not) currenty a pressor requirement ***
We’ve sent *** and are waiting for *** to come back.
Today, I propose we ***

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 413 boilerplate words
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: