Sepsis

kfortune@bmcf.comkfortune@bmcf.com
in Clinical & Coding

I need some help please.  We have an 83yr old male that came into the ED for confusion (AMS).  In the ED, he was diagnosed with UTI.  WBC-18.4 Lactic Acid 3.9 He was afebrile and HR <90 and resp normal.  His primary dx was metabolic enceph.  The ED doc did mention sepsis due to UTI.  However, sepsis was not documented anywhere else in the chart. 

My question is-Should I query the admitting MD for sepsis? 

Comments

  • bbogda@morrishospital.orgbbogda@morrishospital.org
    Were there reasons that his vitals were wnl?  Was he febrile pta?  Was he on antipyretic or beta blocker or was he immunocompromised?  I look for a description in the ED record of how the patient presented.  With the labs and TME, I think there is good cause for asking about sepsis.  Sometimes we find that the diagnosis of sepsis  is almost forgotten (and not carried through progress notes) especially if the patient improves quickly with treatment.
  • katysuegood@gmail.comkatysuegood@gmail.com

    what is the etiology of the encephalopathy. Was it 2/2 infection? If so, we may meet Sepsis-3 criteria (if you have adopted it). His LA is high. How was his BP?


    Katy

  • kfortune@bmcf.comkfortune@bmcf.com
    The MD did state that the encephalopathy was 2/2 infection.  He was hypertensive.  We haven't adopted Sepsis-3 criteria yet.
  • proddy@clarionhospital.orgproddy@clarionhospital.org
    I would query for sepsis and see if the attending concurs with the diagnosis.  I've always coded from the ER record as well as the attending notes and ask for concurrence if there is any question
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