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Flu-like illness

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 42-year-old female with DM presents to the ED for a flu-like illness.  This morning she woke with chills, subjective fever, cough, headache vomiting x 1 and feeling weak.  She also has SOB, pleuritic CP and epigastric pain. ?She denies cough, diarrhea, dysuria or other symptoms.

Vital Signs & Physical Exam:

Vital signs: Temp 102.3, HR 126, BP 105/45.   Physical exam notable for a positive jolt sign but no photophobia or neck stiffness, clear lungs, epigastric tenderness and tachycardia

Initial Differential Diagnosis:

  • Influenza
  • Meningitis
  • PE
  • Pneumonia
  • Sepsis
  • Pancreatitis

Initial Diagnostic Testing:

  • CBC: WBC 8.2
  • Chem 7: normal except for glucose 203 and bicarb of 21
  • Imaging: CXR normal
  • Other: UA and CSF normal
  • Re-eval: feels a little better.  LP normal.  Repeat vitals: Temp 100.1, HR 97, BP 96/55

QUESTIONS:

  1. What do the lab results suggest?
  2. Should you diagnose URI and send her home?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What do the lab results suggest? Depends on the differential.  For this patient, sepsis because WBC normal with very high 92 % PMN
  2. Should you diagnose URI and send her home?  No.  Also, did you notice her shock index is >1
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

PLACE PAGE HERE

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CASE CONCLUSION: Group B strep in 2/2 bottles at 12 hours.  Repeat CBC showed 40 bands the next day

CASE LESSONS:

  1. Scrutinize the differential of the CBC.  PMN >70% is a good rule of thumb for abnormal but the higher it is the more you should worry, ESPECIALLY if the WBC count is low, normal or not that high.  When the PMN count or WBC count are elevated from demargination rather than infection, they are both moderately high, like in the 70-80% and 11-16K range.  Be sure to always look for bands, toxic granulation, vacuoles and Dohle bodies.  These are all big red flags.
  2. Always
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