Critical analysis of the history and physical examination findings from a patient consultation. This will focus on the Diagnostic Reasoning process relating to a particular patient problem and the current evidence base.
This essay will focus on the history and examination findings of a patient who presented with severe sepsis as detailed in case review 1 (appendix 1). Sepsis is a syndrome rather than a specific disease which presents in large numbers throughout the UK, every year there are 150,000 cases of sepsis and 44,000 deaths – the total number of deaths from sepsis in the UK is larger than those dying from breast, bowel and prostate cancer combined (Sepsis Trust UK 2014). Sepsis is not a new phenomenon and has been used since the forth century BC by Hippocrates to define organic matter putrefaction (Pettigrew 2014). Modern attempts to define sepsis have evolved with technological advances and updated management plans (Singer et al 2016). An international panel of experts from critical care have recently presented a new definition of sepsis known as ‘Sepsis – 3’:
“Life threatening organ dysfunction caused by dysregulated host response to infection” (Singer et al 2016)
The consensus on a simple definition of sepsis is hoped to help with a quicker response to diagnosis because severe sepsis is often poorly recognised and poorly treated (Sepsis Trust UK 2014). Severe sepsis occurs when the body is invaded by an organism and the subsequent manifestation of the infection systemically induces organ dysfunction and hypoperfusion (Dellinger et al 2013). The difficulty with diagnosing sepsis is that because it is a syndrome resulting from another disease it is often not recognised early enough and severe sepsis is a time critical condition where a delay in giving vital intravenous antibiotics increases mortality (NICE 2016). Using a specific tool designed to highlight the possibility of sepsis has been advocated to improve recognition of the patient as suffering with sepsis (Singer 2014) and tools to guide practitioners in making a diagnosis are available such as the Red Flag Sepsis Criteria (Sepsis Trust UK) and quick Sepsis related Organ Failure Assessment – qSOFA (qSOFA 2014).
This analysis of the case history will focus on:
- the process required to diagnose sepsis, which has many definitions and tools to aid diagnosis.
- examining which tools provides the most accurate aid for diagnosis by critically analysing the specificity and sensitivity of the clinical criteria and developing definitions for sepsis.
- using a process of diagnostic reasoning to ensure patient safety within the process of diagnosing efficiently and accurately when presented with a life threatening condition such as sepsis.
Case History 1
The patient (Mr B) was an 89 year old gentleman who presented in a collapsed state on a cardiology ward. He had been treated 3 weeks before his collapse with percutaneous coronary intervention to re-open blocked coronary arteries following an ST elevation myocardial infarction (STEMI). The review was undertaken as part of my role as a critical care outreach sister following a referral from the cardiology registrar, when there seemed to be no immediate cardiac cause for Mr B’s deteriorating condition. The patient was unconscious with profound hypotension following a night of confusion and agitation. He had been being prepared for discharge to a ‘community bed’ in the next couple of days.
Mr B therefore had presented with two main urgent concerns:
- He was deeply unconscious with no immediately obvious cause
- He was in shock with profound hypotension
The priority was to assess Mr B to ensure immediate life saving treatment but also to diagnose the cause for collapse and instigate targeted treatment. Shock occurs as perfusion to organs is insufficient because the available circulating blood volume is not under the correct pressure to travel around the body. This reduction in pressure can be from cardiogenic shock or peripheral circulatory collapse due to hypovolaemia from fluid loss or hypovolaemia from a distributive cause such as septic shock, neurogenic shock. (Bennett et al 2015). Mr B needed an urgent history and clinical assessment to treat his life threatening illness.
History Taking and Diagnosis in an Unconscious Patient
Taking a history from a patient is the patient’s account of their own illness and at the end of the discussion the reviewer should have a general idea of the patient’s problem (Thomas & Monaghan 2007). Peterson et al (1992) reviewed the history and examination of 80 patients in a medical outpatient department and found 76% of the patients were diagnosed from history taking alone, before any clinical examination was started. ‘Mr B’ was not able to answer any questions as he was unconscious, therefore any chance to get the patient’s own version of events was not possible. A patient with an altered conscious state cannot give the usual answers to a history, so a collateral history needed to be undertaken from witnesses, relatives and staff. Important history questions to bystanders need to include recent symptoms, past medical /drug history and an urgent review of the patient’s notes after any urgent care has been assessed and delivered, such as airway management. (Cooksley & Holland 2013). Along with the difficulties presented with a patient who cannot answer and questions, was the problem that Mr B was also critically unwell and required procedures and treatment to stabilise his condition in parallel to making a diagnosis. Therefore collateral history taking in an emergency situation also requires attention to examination, investigation and treatment at the same time as acquiring a bystander history (Campbell & McCormick 2002).
To facilitate a comprehensive review of the patient’s presenting complaint and ensure parallel lifesaving treatment to prevent further deterioration the Resuscitation Council (UK) (2015) advocate using a structured approach such as Airway, Breathing, Circulation, Disability, Exposure (ABCDE). The ABCDE structure ensures that at each stage any necessary lifesaving interventions, to prevent further deterioration, are undertaken prior to moving on to the next stage in the system. Once the patient has been assessed and treatment initiated, then a secondary survey can begin including thorough history with clinical examination and commencement of investigations (Bennett, Robertson & Al-Haddad 2015).
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The ABCDE approach to reviewing a critically unwell patient necessitates beginning with a review of the patient’s airway – ‘A’. Mr B was not responding to any verbal or physical stimulation and as he was unconscious I inserted an oropharyngeal adjunct to protect his airway. Cooksley & Holland (2013) support the use of airway adjuncts in patients with a Glasgow Coma Score of less than 8/15. Tolerating an oropharyngeal airway is a demonstration of deep unconsciousness and Mr B was recording a Glasgow Coma Score of 3/15. The Glasgow Coma Score is a widely used scale to score coma which is defined as:
“a deep state of unconsciousness characterised by the absence of arousal or awareness” (Tan & Fedi 2013)
The Glasgow Coma Score determines the level of response to escalating stimuli and has three components; eye opening, motor function and verbal response. Mr B was not opening his eyes, was not responding to noxious stimuli (including the presence of an oral airway) and was nonverbal. Mr B was scoring 1 point in each of the 3 categories which gave him a score of 3 out of a possible 15. This lack of responsiveness was very concerning and led Mr B’s home team to diagnose a probable brain injury following the commencement of anti-coagulation therapy to prevent any new myocardial insult. However as a critical care outreach nurse I am aware that critically ill patients often display unconscious for many reasons such as hypoxia, sepsis, hypothermia and electrolyte disturbance (Bennett et al 2015). I continued to proceed through my assessment whilst receiving the bystander history from the nurses. Tan & Fedi (2013) suggest that the collateral history of a patient who presents as unconscious should focus on:
- time course of alteration in consciousness
- presence of premonitory signs
- the setting
- active and past medical and surgical relevant conditions
I ascertained that Mr B had presented following a period of confusion overnight, which was unusual for him, prior to his collapse which is suggestive of a metabolic process rather than an acute presentation of unconsciousness which is suggestive of stroke (Tan & Fedi 2013), he also had no premonitory signs of brain injury such as headache or any focal neurology, his collapse took place in a hospital setting with no possibility of ingesting sedatory medication that would have induced reduced unconsciousness, unless he accidentally had received extra sedation which a review of his prescription had revealed no evidence of over sedation with analgesia or night sedation. The immediate priority was to improve Mr B’s hypotension and ensure his airway remained patent whilst continuing with his clinical assessment (Schmidt & Mandel 2016). Following stabilising his airway and aiming to improve the circulation with intravenous fluids the next priority was to decide if sepsis was the cause of the collapse, because antibiotics need to be administered as soon as sepsis is recognised. Diagnosing sepsis has always been difficult because of the variety of causal agents but tools have been developed to guide clinicians in recognising pertinent symptoms and red flags to alert to potential sepsis diagnoses.
Diagnostic Tools for Sepsis
With the new definition of sepsis 3 (JAMA 2015) a tool to help guide the diagnosis of sepsis was developed called the quick Sepsis related Organ Failure Assessment (qSOFA 2016). The scoring tool focuses on 3 criteria which are then calculated to give a score to predict the likelihood that the presenting symptoms are demonstrating the possibility of sepsis which may identify patients who are at a risk of high mortality. The three criteria are :
- Systolic blood pressure < 100mmHg
- Respiratory rate >22 breaths per minute
- Altered mental status, measured by a GCS less that 15
Each of the criteria scores 1 point and the parameters are entered into a qSOFA calculator which then predicts the patient’s likely mortality. Mr B had a 23% mortality risk and scored a point in each of the categories when his data is applied to the scoring system. Thus demonstrating that he was ‘very likely’ to be septic.
The tool is very simple and quick to use, however, Chris Nickson (2016) argues that qSOFA has only been validated with retrospective data within the ICU and has not established what amendments need to be made for patients who already score points for pre existing co-morbidity, nor has it been tested on ward patients or pre hospital collapsed patients. The qSOFA score has been chosen by many UK and international hospital institutions to replace previous criteria and diagnostic tools to guide the confirmation of sepsis in a patient. Currently in the UK the qSOFA awaits further validation and the National Institute for Health and Care Excellence (NICE) has not adopted using qSOFA as the diagnostic tool for sepsis and are recommending the use of the Red Flag Sepsis (UK Sepsis Trust 2014) tool to guide clinicians.
Red Flag Sepsis uses two parts to the identification of sepsis by screening for Systemic Inflammatory Response Syndrome (SIRS) and then screening for the level of sepsis severity (Sepsis Risk Stratification) by combining SIRS criteria with the National Early Warning Score (NEWS) track and trigger system for recording physiological observations (Royal College of Physicians 2012), to identify the risk of sepsis. Combining NEWS with SIRS has added more use to the tool because the use of SIRS alone does not present with sufficient sensitivity as 1:8 patients with sepsis do not have 2 or more SIRS criteria nor is it specific enough as 4:5 patients in ICU have SIRS criteria without infection (Kaukonnen et al 2014). Butterworth (2015) described red flag sepsis as being highly sensitive and demonstrating high levels of specificity when retrospectively analysing pre hospital cases through the paramedic services. Applying the red flag sepsis criteria to Mr B demonstrated that he fulfilled the SIRS criteria and had hypotension with a reduced GCS so he fulfilled the red flag criteria for a diagnosis of severe sepsis.
Shankar-Hari (2015) discuss quality of septic shock criteria and definitions. They argue that hypotension alone displays poor face validity as a core presenting component of diagnosing sepsis because hypotension could be triggered by medication administration, sedation, cardiac impairment or all of the above. Equally measurements of organ hypoperfusion do not show sufficient specificity to septic shock as measured serum base deficit elevation and hyperlactaemia are present in cardiogenic or neurogenic shock (Dellinger et al 2013). The authors (Shankar-Hari 2015) argue that a concurrent criteria which uses cardiovascular parameters in conjunction with measurements of tissue perfusion abnormalities are more likely to better predictive validity, red flag sepsis fulfils this combined approach. Diagnostic tools can confirm whether a patient has a specific condition but a clinical examination is vitally important to investigate signs that are pertinent, both negative as well as positive.
Being Suspicious of Sepsis
Mr B displayed hypotension and a change in GCS but a striking feature of his deterioration was the symptom that Mr B was very warm to touch peripherally. Schmidt et al (2016) describe a warm flushed appearance as being a key finding when examining a patient with septic shock. A differential diagnosis for Mr B would have been cardiogenic shock as Mr B could have extended his STEMI that he had experienced three weeks before, but cardiogenic shock produces cool peripheries as opposed to distributive shock which elicits warm dilated peripheries (Bennett et al 2015).
Diagnostic tools are helpful to confirm diagnosis but when completing thorough history and examination Ron Daniels (2015) argues that the diagnosis of sepsis should require a constant suspicion and that any patient who presents as unwell should be considered as having sepsis. The application of definitions and diagnostic tools needs to be applicable to prehospital areas so decisions about treatment or admission to hospital can be done quickly, therefore the qSOFA score which measures the severity of sepsis from an ICU perspective may not be sensitive enough for prehospital patients with early signs of sepsis and may not be specific enough for patients with existing co-morbidity. Ron Daniels (2011) described in his discussion about surviving sepsis that early identification of sepsis requires awareness, vigilance and knowledge but then also requires the practitioner to initiate early treatment to halt the progress of the disease which has such significant mortality.
Using Diagnostic Reasoning in Septic Patients
Using diagnostic tools such as qSOFA or red flag sepsis tool are helpful to confirm initial suspicions but whilst examining Mr B, I was utilising the hypothetico-deductive method to diagnose his unknown cause for collapse. Rajkomar & Dhaliwal 2011 describe this model as a process where hypotheses are “proposed, tested and either verified or rejected.” Using the ABCDE framework to guide my diagnostic investigation I worked through the list, starting at the life threatening elements first and then decided whether any potential causes for Mr B’s collapse were plausible.
A neurological cause for Mr B’s unconsciousness would be a sound consideration but he had no history of seizures, pupillary changes, facial droop or any complaints of headache prior to his decreased conscious level (Tan & Fedi 2013), thereby allowing me to initially rule out these pertinent negative findings as an immediate cause which I could investigate once Mr B’s condition had stabilised with further brain imaging if he remained unconscious despite improved blood pressure recordings.
Coronary causes for Mr B’s collapse would also have been a reasonable diagnosis as Mr B was in the recovery phase of his STEMI but Mr B did not have any recent history of chest pain, nausea or breathlessness prior to his collapse and the 12 lead ECG ordered during the ABCDE assessment did not demonstrate any significant changes to illustrate decreased coronary perfusion. These negative findings were also confirmed by a low troponin level sent during urgent blood sampling following his collapse.
Sepsis with hypotension became my working hypothesis particularly with a history of confusion over night that I had gained from the bystander history. I asked for the patient to have a full septic screen performed and treatment to be commenced following the ‘Septic Six’ algorithm (Sepsis Trust UK 2014). This bundle of interventions is designed to investigate and treat sepsis within one hour of sepsis being identified as a potential cause for a patient’s deteriorating condition. The bundle consists of six interventions:
- Administer high flow oxygen
- Take blood cultures and consider infective source
- Administer intravenous antibiotics
- Give intravenous fluid resuscitation
- Check haemoglobin and serial lactates
- Commence hourly urine output measurement
Following catheterisation Mr B had urinalysis performed and this demonstrated the potential presence of infection and as Mr B had recently completed antibiotics for a previous urinary tract infection this seemed the most likely source of his sepsis. He was given intravenous antibiotics and responded well to the administration of intravenous fluids without requiring inotropic support for his blood pressure. Mr B was transferred to CT scan to ensure he did not have a neurological cause for his unconsciousness. The scan did not find any evidence for brain injury.
Lessons learnt from Mr B’s Collapse
Assessing Mr B’s collapse reaffirmed for me the importance of being methodical and thorough when dealing with an emergency. Using ABCDE assessment to examine pertinent positives and negatives assisted my hypothesis development but also allowed me to instigate investigations that would confirm my diagnosis at a later stage. There is no current definitive test for sepsis, although work is being done to determine measurements of certain biomarkers (Carrigan et al 2004) but even the presence of a definitive test still needs the initial signs of sepsis to be recognised and acted upon. Suspicion of sepsis and the use of a tool to decide on the likelihood of infection remains the only way to affirm the presence of sepsis syndrome. My organisation use red flag sepsis and my awareness of the different criteria has been strengthened by looking at the evidence for combining SIRS and NEWS whilst preparing for this essay. qSOFA looks a more simple tool to use but concerns about the lack of validation across specialties means that we are unlikely to use it until it is recommended by government and professional bodies. However I have been able to share with my critical care outreach team the developments of Sepsis 3 definitions and the alternative method that qSOFA offers for my team when assessing critically ill patients.
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Case Review 1 – Sepsis
NHS number : 434 228 3867 Date of birth 06/01/26
Asked to review a 89 year old patient with sudden collapse on a cardiology ward.
Patient found in bed unresponsive with Glasgow Coma Score of 3/15 and hypotension 55/25mmHg -recorded using manual sphygmomanometer. Unknown cause for collapse. Currently patient is supine and remains unresponsive but is breathing and has palpable pulse. Nursing staff and junior doctor present.
History of Presenting Complaint
Patient was 3/52 post myocardial infarction and had been treated with percutaneous coronary intervention following an acute anterior myocardial infarction. He was stabilised on warfarin and a beta blocker and was being prepared for discharge home.
He had was found to have urosepsis on admission and had completed his antibiotic course 2/7 before his collapse.
Overnight the nursing staff reported that the patient had been unusually confused and had pulled out his urinary catheter.
Past Medical History
Angina – uses glycerine trinitrate spray on exertion with good effect.
Hypertension – takes prescribed antihypertensive medication for last 5 years.
Chronic kidney disease (CKD) stage 2 – under the care of renal team for management of CKD.
No history of jaundice; tuberculosis; rheumatic fever; epilepsy; asthma; diabetes or stroke.
No known drug allergies
GTN as required
Amilodipine 5mg daily
Aspirin 75mg daily
Warfarin 2mg – recently commenced
No over the counter preparations
Smoking, Drugs and Alcohol
No alcohol or illicit drug use
Ex smoker – gave up 25 years ago, previously smoked one pack of cigarettes per day.
Lives independently in a bungalow, no formal support currently. Daughter helps with shopping as patient no longer drives. Mobilises independently without aids. No pets or recent travel abroad.
Widowed 10 years ago. Wife died of breast cancer.
Both parents dead, father died of MI and mother died of CVA. No siblings – only child.
One daughter who lives nearby and visits home once per week.
Collateral history of review of systems gained from medical notes/ home team and nursing staff as patient was unable to respond.
- General – No recent weight loss or lethargy
- Respiratory – No recent productive cough or SOB. Not known to experience wheeziness.
- Cardiac – Moderate SOBOE/angina and utilises GTN successfully. Recent anterior MI and subsequent PCI. No ankle oedema or orthopnoea.
- Gastrointestinal – Bowels opened yesterday -type 3. No history of nausea or vomiting or indigestion.
- Genitourinary – Recently completed antibiotics for UTI. Catheterised due to retention 3/7 ago. Previously no complaints of freuency of micturition. Not investigated for enlarged prostate recently.
- Neuro – Independently mobile and had been orientated to time, place and person before new confusion last night. No history of seizures or blackouts.
- Locomotor – No history of joint pain or stiffness.
- Skin – Skin intact with no history of skin damage
- Patent airway, no signs of obstruction or compromise. No airway adjuncts in situ. Trachea palpable in the midline. Oxygen at 15 litres per minute via non-rebreathe mask.
- No signs of previous surgery or injury on inspection. Air entry equal and symmetrical bilaterally. No tactile fremitus on palpation. Resonant percussion throughout both lung fields. No adventitious signs upon auscultation.
- Respiratory rate – 26 breaths per minute. Oxygen saturation 97%.
- Precordium inspection reveals no visible heaves. Apex beat not visible. No palpable parasternal heaves or thrills. Apex beat palpable at 5th intercostal space mid-clavicular line, approximately 4 cm in diameter, ‘bounding’. Auscultation of heart sounds normal
- S1 + S2 + 0
- Very dilated peripheries, capillary refill time 3 secs on sternum. Central temperature 38.4â„ƒ
- Both calves soft and non tender, no skin discolouration.
- Blood Pressure – 55/30mmHg, Heart Rate – 135 bpm. JVP measured at 1cm above sternal angle. Oral mucosa dry. No recent recorded fluid balance chart. Last known to have been incontinent of urine three hours ago, urinary catheter removed by patient during night.
- No signs of haemorrhage, leuconychia or clubbing.
- Unresponsive with GCS 3/15. Eye opening – no response; Motor response -none; Verbal response – none (E1,M1,V1). Pupils equal and reacting to light size 2. Capillary blood glucose 8.6mmols/litre. Tone – floppy, reflexes brisk, plantar reflex down. No signs of seizures. Patient reportedly confused overnight – trying to get out of bed and disorientated.
- Intravenous cannula to both antecubital fossas recently inserted. IVI 500ml bolus of saline over 15 minutes in progress.
- Recent bloods to note (2/7 ago):
- WCC raised to 23, CRP 254, Hb 123, Urea 9 Creatinine 112, eGFR <54
- No recent lactate or troponin since previous MI
Cardiovascular shock due to severe sepsis
- Cardiogenic shock due to myocardial infarction or pulmonary embolism
- Cerebrovascular event due to over-anticoagulation or stroke
- Oro-pharyngeal airway
- Continue fluid resuscitation until BP within normal parameters
- 12 lead ECG
- ABG with lactate measurement please
- Chest X-ray
- Urgent bloods including U & E’s, FBC, Clotting screen, CRP, Lactate, troponin levels
- Blood cultures
- IV broad spectrum antibiotics
- Urinary catheterisation and urine dip +/- M.C &S sample
- Consider CT Head
- Review treatment and escalation plan with home team and ICU consultant
The patient’s blood pressure had responded to IV fluids but he had needed 2 litres of Hartman’s solution in total. He received a stat dose of IV Piperacillin and Tazobactam 4g/0.5g for presumed sepsis.
The patient remained unresponsive so was transferred to CT scan for a urgent CT head, in case of a cerebrovascular event following commencement of anticoagulation. The CT head was normal.
ABG showed a metabolic acidosis with a lactate of 5. All inflammatory markers were raised and his renal function had deteriorated significantly. The patient was not transferred to the high dependency unit and a decision had been made not to escalate his care beyond level 1 (ward based) intervention. He had a Do Not Attempt Cardio Pulmonary Resuscitation order completed following discussion with his daughter.
The patient ‘woke’ up the following morning and responded well to antibiotics. He was discharged to Care In the Community bed but sadly died two weeks later.
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