Severe sepsis with septic shock
ICD-10 R65.21 is a billable code used to indicate a diagnosis of severe sepsis with septic shock.
Severe sepsis with septic shock is a critical condition characterized by a systemic inflammatory response to infection leading to organ dysfunction and hypotension. Symptoms may include fever, chills, rapid heart rate, confusion, and difficulty breathing. Clinically, patients may present with signs of organ failure, such as altered mental status, decreased urine output, and elevated lactate levels. Laboratory findings often reveal leukocytosis or leukopenia, thrombocytopenia, and elevated inflammatory markers like C-reactive protein (CRP) and procalcitonin. Septic shock is defined by persistent hypotension despite adequate fluid resuscitation, requiring vasopressor support. This condition demands immediate medical intervention and is associated with high morbidity and mortality rates, necessitating prompt recognition and treatment.
Detailed notes on patient history, physical examination findings, and lab results indicating organ dysfunction.
Patients presenting with fever, tachycardia, and altered mental status in the context of known infections.
Ensure all organ systems are evaluated and documented to support the diagnosis of severe sepsis.
Immediate assessment findings, including vital signs, lab results, and response to initial treatment.
Acute presentations of patients with suspected infections leading to shock.
Rapid documentation of interventions and patient response is crucial for accurate coding.
Used when a patient with severe sepsis presents to the emergency department.
Document the severity of the condition and the complexity of medical decision-making.
Emergency medicine providers should ensure thorough documentation of the patient's condition and treatment.
Severe sepsis is characterized by organ dysfunction due to infection, while septic shock is defined by persistent hypotension despite adequate fluid resuscitation, indicating a more critical state.
