Clinical Opal #9 - 64 year old with fever and rigors
Joan is a 64-year-old hospital cleaner who presents to you one morning feeling 'dreadful'. Joan has a past history of well controlled diabetes and takes metformin 500mg bd. She also has hypertension, managed with lercanidipine. Joan is a non-smoker and non-drinker, and identifies as Aboriginal. Of note, she had a cystoscopy four days previously for investigation of haematuria.
Joan describes fevers overnight and two episodes of uncontrollable shaking. She feels weak and exhausted. She says that her urine has been burning but denies any frequency or abdominal pain.
On examination, Joan looks unwell and her peripheries are cool and clammy. She has a temperature of 38.1, RR 26, BP 113/70, HR 108, O2 sat 96%.
What important condition must be considered in your assessment of Joan?
The most important condition to consider in Joan's case is sepsis, most likely related to a urinary tract infection.
Sepsis is characterised by life-threatening organ dysfunction caused by an abnormal response to infection. Prompt recognition and treatment is vital, as time-critical resuscitation, antibiotic therapy and organ support reduces morbidity and mortality.
Sepsis is more likely in the elderly, and those patients with an underlying malignancy, immunosuppression, or who have had recent surgery. The signs may be subtle, and include hypo- or hyperthermia, tachycardia and confusion. Life-threatening organ dysfunction is indicated by the following features:1
- tachypnoea (RR> 22 breaths/minute)
- hypoxaemia
- hypotension (sBP <90 mmHg)
- impaired consciousness
- poor peripheral perfusion or mottled skin
- acute oliguria
- blood lactate concentration more than 2 mmol/L.
Patients with suspected sepsis need urgent fluid resuscitation and transfer to hospital. If there is likely to be a delay of one hour or more in transfer, for example in rural or remote areas, take blood cultures and administer broad spectrum antibiotics.2
Related courses
References
- Therapeutic guidelines. Early recognition of sepsis in adults.
- Australian Sepsis Network
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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