The stem suggests:

severe sepsis ( vital signs show a SIRS response)

Consider stage of cancer and intervention required.

Risk of Pulmonary embolism.

This is a critically unwell patient with septic shock and multiorgan dysfunction syndrome (MODS), requiring management as per surviving sepsis guidelines, appropriate investigation and early involvement of ICU. Immediate interventions include fluid replacement (up to 3 litres max), broad spectrum antibiotics, blood cultures, source control, invasive monitoring and inotropic support. Careful attention to oxygenation and ventilation, with intervention if deterioration (indications for intubation – worsening hypoxia, fatigue, altered mental state, CO2 retention etc). If CXR does not show obvious source, patient requires CTPA (risk/ benefit in view of renal failure).

Discuss prognosis with patient and family. His very high lactate suggests a poor prognosis.

FBC:

mild macrocytic anaemia – chemotherapy related, B12, folate, alcohol, other

Sepsis – very high WCC and Neutrophils – leukaemoid reaction, secondary malignancy (leukaemia after chemotherapy – requires examination of blood film)

Evidence of end organ failure:

Anaemia

Coagulopathy – low platelets, high INR, low fibrinogen (care with invasive lines)

Renal failure – high urea and creatinine

high lactate – shock and failure of perfusion of end organs

Others to look for – altered mental state, liver failure, cardiac dysfunction (APO, raised trop), ARDS

ABG: (SHOW CALCULATIONS)

moderate to severe high anion gap metabolic acidosis with additional respiratory alkalosis. Hypoxic on 15 litres non re breather. A-a gradient very high indicating VQ mismathch or shunt ( PE, pneumonia, aspiration, pneumothorax). The delta gap is 1.8 which would indicate a pure HAGMA (mostly accounted for by the lactate). Above 2 may indicate a co exisiting metabolic alaklosis.

This interpretation was not the usual format but indicates more of what is required at Fellowship level.

SIRS:

HR >90/min

RR >20 or pCO2 <32

T <36, >38

WCC <4 or >12

SEPSIS – SIRS plus evidence of infection

SEVERE SEPSIS:

lactic acidosis

SBP <90 or drop of >40

SEPTIC SHOCK:

Hypotension despite adequate fluid resuscitation

MULTIPLE ORGAN DYSFUNCTION CRITERIA:

Evidence of 2 or more end organ dysfunction