Author: Ciara Fitzpatrick Osborne, Brigid Collins / Editor: Nick Tilbury / Codes: EnC2, MuC3, MuP2, RP6, SLO3 / Published: 31/05/2023

An 81-year-old Nursing Home resident attends the emergency department (ED) in your district general hospital (DGH).

The paramedics tell you she has been feeling generally unwell for two days and also has a painful right hip on mobilising. There is no report of trauma.

The nursing home staff apparently noticed she had a reduced urine output over the previous 24 hours. There has been no recent vomiting or diarrhoea and no recent infection outbreaks in the nursing home.

Her past medical history includes Baker’s cyst, OA, Diabetes, IHD and dementia with a baseline GCS 14/15.

The patient appears clammy and pale with an inability to verbalise her reason for attendance.

Her examination findings are as follows:

  • HR 124
  • BP 96/63
  • RR 22
  • Temp 34.9°C
  • Sp02 94% on room air
  • GCS 14/15.

Chest is clear on auscultation

Heart sounds are normal with no added sounds

Abdomen is soft but has generalised tenderness on palpation

There is limited active movement of both hips but there is no obvious injury or bruising to the pelvic area including the hips. The right hip appears more painful than the left on passive movement.

Both legs appear mottled.

A venous blood gas (VBG) and ECG are done:

  • VBG: pH 7.264, HC03 12.9, Lactate 11.5, Glucose 24.7, Ketones 3.4
  • ECG: Sinus tachycardia

A Bair hugger is applied to the patient and initial treatments include an IV fluid bolus and Piperacillin with tazobactam 4.5g IV as per NICE guidelines for sepsis1.