Case Details The patient, in this case,

Case Details The patient, in this case, was a 49-year-old female who had a significant medical history, including chronic obstructive pulmonary disease (COPD), coronary artery disease, hypertension, and hyperlipidemia. Her surgical history included the placement of two coronary stents and vascular surgery on her left leg. She presented to the emergency department (ED) on a Thursday afternoon reporting abdominal pain, right flank pain, and shortness of breath. Although the patient had previously been prescribed multiple medications, she stated that she had not taken them for 2 months because of the cost. Her temperature was 101 degrees and her blood pressure (BP) was 187/111 mmHg. Dr. A examined the patient and ordered lab tests, including a comprehensive metabolic panel, complete blood count, urinalysis, urine culture, and blood cultures from two separate sites. He also ordered a computed tomography (CT) scan of the pelvis and abdomen. During the physical exam, Dr. A noted decreased bowel sounds. The patient’s abdomen was soft and tender with no guarding or rebound, but she did have costovertebral angle tenderness in the lower back. The patient’s lab results were normal with the exception that white blood cells (WBCs) were 16,000/mm3 , segmented neutrophils were 98.6 percent, and glucose was 127 mg/dL. Dr. A felt that the elevated WBC count with a left shift indicated a urinary tract infection (UTI). The CT scan of the abdomen and pelvis showed a 5×7 mm stone in the right ureter with moderate right hydronephrosis. Dr. A believed that the patient’s shortness of breath was due to pre-existing COPD. He ordered and the patient was given ketorolac, ondansetron, and morphine for her pain. Dr. A did not consult the on-call urologist, Dr. U, because the urologist did not like to be contacted unless the patient was going to be admitted to the hospital — and Dr. A did not plan to admit the patient. He felt that pain control was the only possible cause for admission. The patient was discharged after several hours, and Dr. A’s clinical impression was acute abdominal pain, renal colic, and UTI with fever. The patient was instructed to follow up with the urologist as soon as possible as well as a primary care doctor regarding her other medical issues. She also was given prescriptions for ciprofloxacin and a hydrocodone combination product. Dr. A told the patient where she could have the prescriptions filled for free or very inexpensively. She was instructed to return to the ED if her problems persisted. The patient returned to the ED early the next morning (Friday), and she was seen by a different emergency physician, Dr. B. She told Dr. B that she had been diagnosed with gallstones the previous day. After reviewing the records, Dr. B concluded that the patient was confusing gallstones with kidney stones, and he assumed that Dr. A had talked to the urologist during the patient’s previous visit. In actuality, the patient had not yet made an appointment with the urologist or filled her prescriptions. She was still suffering from right flank pain and was rocking on the edge of the bed due to pain. She also stated that she had not urinated very much. The patient’s vital signs were as follows: BP = 151/86 mmHg, pulse = 93 beats/minute, respirations = 24 breaths/minute, and oxygen saturation = 97 percent. She had a temperature of 96.8 degrees. Dr. B was aware that blood cultures from the previous day were available, and that the cultures showed gram-negative rods. However, the sensitivity report was not back to the ED yet. He ordered and the patient was given ondansetron, morphine, ketorolac, and oral ciprofloxacin. The patient didn’t want to take the ciprofloxacin, but Dr. B had a serious discussion with her about the need for the medications and the urgent need to see the urologist. She ultimately was convinced to take the medication. Dr. B did not order any lab tests or procedures, but he strongly encouraged the patient to contact the urologist that morning for an appointment. She was told to return to the ED if her condition worsened, and she agreed to do so. No documentation exists regarding any conclusions drawn as to the patient’s lack of urination. The patient did fill the initial ciprofloxacin prescription later that day. The patient returned to the ED for a third time the next day (Saturday), and she was seen by a third emergency physician, Dr. C. The patient was confused and had a fever. She still had not contacted the urologist. Dr. C’s impression was dehydration, neutropenia, urosepsis, and ureterolithiasis. Dr. C admitted the patient to the hospital, and she had a stent placed in the right ureter by the urologist and was admitted to the intensive care unit. The patient had a difficult course; she developed pneumonia and suffered a massive stroke approximately a week after the third ED visit. Further complications developed, and the patient died several days after having the stroke. SIRS and Sepsis SIRS consists of four criteria, and patients must have two or more. The criteria are as follows: • Temperature: >100.4° or <96.8° • Respiratory rate: >20 breaths/minute • Heart rate: >90 beats/minute • WBCs: >12,000/mm3 or <4,000/mm3 Sepsis is defined as SIRS plus suspected or confirmed infection.1 The patient's family filed a lawsuit alleging negligence on behalf of Drs. A and B. The basis of the lawsuit was that the patient met both the criteria for systemic inflammatory response syndrome (SIRS) and sepsis. Discussion Questions: 1. What went wrong in managing this patient? What factors are at play in this case? 2. What are SIRS, Sepsis, and Septic Shock (pathophysiology, signs, and symptoms) with rationale? Relate the patient's symptoms and investigation reports. 3. Which algorithm should be used during triage assessment to screen patients with severe sepsis? 4. How to treat sepsis including pharmacological management. Share the stepwise approach using international guidelines. 5. How could the patient's death be prevented? want detail answers with references SCIENCE HEALTH SCIENCE NURSING NUR 123

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