Suspected sepsis
Complete SOAP example
Example narrative
79-year-old man from RC, dependent for transfers and usually conversant, has one day of fever, reduced intake and new confusion. Staff report urinary symptoms and no fall. Goals-of-care documents accompany patient.
Primary survey intact with tachypnea. Patient found supine in bed, drowsy but rousable. Temperature elevated; serial BP trending lower with tachycardia. Skin warm, mucosa dry, no focal deficit; BGL measured.
Differential considerations: 1) sepsis from urinary or other infection, 2) dehydration with delirium, 3) medication or metabolic cause. Acute delirium with concerning perfusion trend.
Monitoring, vascular access and treatment provided per applicable sepsis guideline. Serial vitals and mental status reassessed. Transported priority with pre-alert; baseline cognition, goals of care, suspected source and trend communicated.