TREATING SEPSIS

Step D: Detective work - history, physical, immediate investigation

Take a history (or obtain a collateral one), examine the patient, and quantify the extent of sepsis: temperature, white cell count, acid-base status and cultures. The choice of antimicrobial is determined by the source of infection and a best guess of the organism involved.

It is extraordinary how often the diagnosis can be made by taking a good history alone, and how few doctors bother going through the trouble of teasing out the salient details. Even if the patient is too sick to give a history, a good collateral one is usually available. Certain aspects of the history can tip you off to the source:

What symptoms do you have?

• “I have been experiencing sharp episodes of chest pain on inspiration”: lower respiratory tract infection.
• “I have severe abdominal pain boring through to my back”: pancreatitis.
• “I have been having pain passing urine”: urinary tract infection.
• “Persistent dry cough”: atypical pneumonia.

Likewise, even with a collateral history, it is possible to establish the source:

• Has he any medical problems? Yes he has gallstones (cholecystitis, cholangitis), rheumatoid arthritis (steroids /immunosuppressants), etc.
• Has she had recent surgery? Yes she just had bowel surgery (post operative complication).
• Has he been out of the country recently? Yes he just came back from India, and has been complaining of persistent diarrhea (bacterial overgrowth).
• Has she had any recent injuries? Yes, she was in a car crash two days ago, but was sent home from the hospital (many possibilities).
• Does he take drugs? Yes, he injects heroin (endocarditis).
• Any problems recently? Yes, he lost his job and has been drinking heavily (pancreatitis).

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