Sepsis due to Pneumonia Sample Paper
Mr. Parker has presented with telltale signs and symptoms of an underlying pulmonary pathology with cardiovascular complications. He was referred from Emergency Department (ED) to Intensive Care Unit (ICU). Described below are the contributory factors, subjective data, and objective data of Mr. Parker during this admission and care.
Contributing factors are the findings that might have led to his illness or exacerbation of disease presentations. Pneumonia may usually progress to sepsis when the patient has a lowered immunity from whatever cause (Gyawali, Ramakrishna & Dhamoon, 2019). Often, young and the very old are at risk of progression of pneumonia to sepsis due to immature or weaker immunity; Mr. Parker is an elderly patient (aged 60 years).
Subjective is the data provided by the patient, the family member, or the person who brought in the patient. Mr. Parker’s subjective data include lethargy, confusion, shortness of breath, lack of appetite, and a one-week cough. The patient was brought in by the wife who most likely provided this subjective information.
Objective data is elicited by the clinician during physical examination or through tests and clinical investigations (Seo et al., 2016). On examination and assessment, the clinician found out that Mr. Parker had deranged vital signs with low blood pressure (96/58 mmHg), elevated respiratory rate (24), elevated heart rate (130), and temperature of 99.10F. Physical general exam also show elevated confusion, flushed cheeks, dyspnea, and anxiety. The chest exam would reveal bilateral crackles and wheezes, dull percussion note, and unequal chest expansion. An active productive cough with rust-colored sputum would also be observed.
The most recent definition and diagnosis of sepsis entails signs of organ dysfunction with altered mental status, decreased blood pressure below 100mmHg systolic, elevated breathing rate, and identifiable source of infection. The subjective data, objective data, and contributing factors described are consistent with an underlying pneumonia that has complicated to sepsis. The pneumonia is the identifiable underlying source of infection for sepsis in this case.
Sepsis due to Pneumonia Sample Paper References
Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7, 2050312119835043. https://doi.org/10.1177/2050312119835043
Seo, J. H., Kong, H. H., Im, S. J., Roh, H., Kim, D. K., Bae, H. O., & Oh, Y. R. (2016). A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean Journal of Medical Education, 28(2), 237–241. https://doi.org/10.3946/kjme.2016.26