Triage: Stroke code.  LKW 1 h ago when leaving another ER.  Diagnosed with a kidney stone. A0x4 baseline, now only responsive to pain. EMS reported slurred speech, global weakness. No thinners.  Hx: DM

History of Present Illness: A woman in her late 40s with a history of DM Medics stated that she had generalized weakness and slurred speech but no focal weakness but a heart rate of 140 and a temperature of 102.0. According to daughter patient has been complaining of abdominal pain and vomiting but no fever fever headache photophobia cough sore throat or other complaints

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

Physical Exam: °GENERAL: Comatose. Does not move either arm or legs to sternal rub but just cries and moans and then continues crying for prolonged amount of time.
°NEUROLOGIC: No clonus. Protects airway but GCS was initially 4 but gradually did improve while she was here

Initial Diagnostic Testing: CBC essentially normal but CRP elevated at 11 and lactic acid elevated at 3.7. Metabolic panel shows potassium 3.2 bicarb 15 and creatinine 1.3 treated with IV fluids. Troponin elevated at 31 this is likely demand ischemia but aspirin given. Doubt acute ischemia. Code brain called CT angio head shows no large vessel occlusion and CT of the head shows no evidence of stroke.

  • CBC:
  • LFTs:
  • Imaging: see 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

 

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What is the most likely cause of the fever?

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

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

 

CASE CONCLUSION: CT urogram showed an obstructing 3 to 4 mm left UVJ stone.  The rest of the UA was moderate bacteria and positive nitrites.  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 but after 3 days was well enough for discharge home