CT3: Stroke Code*

Triage Note: Stroke code. LKW 2 hours ago. A & 0x4 at baseline, now only responsive to pain. EMS reported slurred speech and global weakness.

History of Present Illness: A woman in her late 40s with a history of DM is brought to the ER by medics for generalized weakness and slurred speech for the past 2 hours. Patient is too altered to provide any history. Family noted no focal weakness but stated she had a temperature of 102.0. Family also notes she has been complaining of abdominal pain and vomiting for the past 12-24 hours. There has been no reported headache, photophobia, cough, sore throat or other complaints.

Vital Signs: T: 38.4 °C (Oral), HR: 109, RR: 22, BP: 106/50, SpO2: 96%

Physical Exam Highlights:

GENERAL: Comatose. Does not move either arm or legs to sternal rub but responds only with cries and moans, which continue for prolonged amount of time after sternal rub.
ABDOMEN: Soft without guarding but patient to altered to assess for tenderness
NEUROLOGIC: No clonus. Toes down-going. Cannot adequately assess for focal findings. GCS initially 4 but soon after improved steadily and is up to 11 within 20 minutes.

Diagnostic Testing:

CBC: essentially normal, but CRP elevated at 11 and lactic acid elevated at 3.7.
Chemistry: potassium 3.2, bicarb 15, and creatinine 1.3.
Urinalysis: Dip negative; micro with 0-5 wbc, 0-5 rbc, moderate hyalin casts and bacteria.
Imaging: CT angio head shows no large vessel occlusion and CT of the head shows no hemorrhage. Chest x-ray normal except low volumes. CT abdomen cut shown below

What is the most likely cause of the fever?

A) CVA
B) UTI
C) AAA
D) SBO

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>

****************************************************************************

THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

******************************************************************************

Quiz Answer: What is the most likely cause of the fever?

A) CVA – not ruled out with testing so far but extremely unlikely to cause fever
B) UTI – CORRECT – UA has moderated bacteria and CT scan shows hydronephrosis on the left
C) AAA – not seen and doesn’t cause fever
D) SBO – not seen. Fever or hypothermia would be a late finding

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

CASE CONCLUSION: CT shows hydronephrosis on the left. Lower cuts showed an obstructing 3 to 4 mm left UVJ stone. The UA was negative for leukocyte esterase and nitrites, and had 0-5 wbc and moderate bacteria. Lack of pyuria should not be used to rule out UTI if clinical suspicion is otherwise high, especially when there is bacteria and the patient is septic as pyuria is <90% sensitive for UTI, even in severe cases and especially in immune compromised patients or those with ureteral obstruction. The urine and blood cultures both grew >100,000 cfu/ml of E. coli. She ended up on 4 pressors in the ICU after urology took her to the OR at midnight for a ureteral stent. After 3 days she was well enough for discharge home.

CASE LESSONS:

Pyuria should not be used to rule out UTI: sensitivity is <90% even in sepsis
CT head rules out bleeds not strokes: You need a delayed MRI to rule out a stroke
CBC is poorly sensitive for serious infection: only about 50% but likely closer to 70% if you used PMN <70% as part of your normal criteria

Test Performance for SBI in Adult ED patient
Fever 50% sensitive / 90% specific
¯ Sodium often low in bad infections
WBC 70% sensitive / 70% specific
ESR 75% sensitive / 75% specific
SIRS criteria 85% sensitive / 60% specific
PMN 85% sensitive / 75% specific
Procalcitonin 85% sensitive / 85% specific
CRP 90% sensitive / 90% specific

THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

Check Out Our Weekly EM Case Challenges

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