CLINICAL PRACTICE : CASE STUDY 1 NAME : DINA ALICE SURNAME : KABIKA STUDENT NUMBER : 17010016 TOPIC : SEPSIS OR SEPTICEMIA LECTURER : Mr. VINCENT NAICKER DATE : 05 NOVEMBER 2018 TABLE OF CONTECT COVER PAGE Page 0 TABLE OF CONTENT Page 1 ABSTRACT, INTRODUCTION AND CASE PRESENTATION Page 2 PATIENT HISTORY AND SECONDARY ASSESSMENT Page 3 PREHOSPITAL TREATEMENT Page 4 & 5 EMERGENCY DEPARTEMENT Page 5,6 & 7 CONCLUSION Page 8 REFERENCES Page 9 ABSTRACT Infections represent a common health problem in people of all ages.
Usually, the response given to them is appropriate and so little treatment is needed. Sometimes, however, the response to the infection is inadequate and may lead to organ dysfunction; this is the condition known as sepsis. Sepsis can be caused by bacteria, fungi or viruses and at present there is no speci?c treatment; its management basically focuses on containing the infection through source control and antibiotics plus organ function support. REMEMBER TO REFER SEVERE SEPTIC SHOCK INTRODUCTION CASE PRESENTATION A 42 years old male patient was brought into the Emergency Department (at Netcare Kingsway Hospital) by paramedics at 10:45 with the history of having seizure in the morning while having breakfast with his family at the restaurant, nothing was done for this patient prehospital with a GCS of 15/15 . On our examination the patient appeared to be tired and sleepy, he had body weakness and was shivering.
At 10:45 His airway was open, clear, maintained and protected by himself. The patient was breathing at 30 breaths per minute (tachypneic), with clear air entry bilaterally, pink in colour, he was not using any accessory muscle and he had an oxygen saturation of 93% and was put on O2 with venturi mask at 8 L/min due to low saturation. Patient had no allergies, he is taking Tribuss, he had a Right arm operation in April 2018, and his last oral intake was breakfast. The patient’s heart rate was 117 beats per minute (tachycardia), which was strong and regular.
His cap refill was good 2 seconds; his BP was 133/77. The patient’s pupils were equal and reactive to light. He had an HGT of 5.3 mmol/L. Patient had no DCAP BTLS, he presented no signs of rashes, he had high temperature 39.90C, ETCO2 was not done, HGT was done once and air entry was clear on auscultations. The patient presented with the following vital signs is these different times: Time 10 : 55 11 : 05 11 : 18 11 : 25 11 : 35 11 : 45 11 : 55 BP 132/84 135/78 104/67 107/65 86/61 85/59 84/49 HR 115 110 115 112 108 106 100 RR 28 28 30 27 26 27 26 SpO2 98 100 92 94 99 100 100 Pupil PEARL PEARL PEARL PEARL PEARL PEARL PEARL T0C Not done 38.30C Not done 37.90C 37.70C Not done 37.40C Perf. < 2secs < 2secs < 2ecs < 2secs < 2secs < 2secs < 2secs Pain Sc5/10 Not done Not done 0/10 0/10 Not done Not done GCS 15/15 15/15 15/15 15/15 15/15 15/15 15/15 ECG ST ST ST ST ST ST SR HGT 5.3 Not done Not done Not done Not done Not done Not done When doing secondary survey or head to toe assessment this is what we found: Head and Neck: No otorrhea, no rhinorrhoea, no pain on palpation; Chest: equal chest rise and fall, no crepitus, no DCAP-BTLS, dry wound on the right side of the chest; Abdomen: soft, not distended; Pelvis: stable, no crepitus, no incontinence; Limbs: PMS present in all four limbs, no DCAP-BTLS, a scar on the right arm (middle the humerus); Back: No pain, on DCAP-BTLS, no abnormality detected.
PREHOSPITAL TREATEMENT EMERGENCY DEPARTEMENT CONCLUSION REFERENCES
