Triage: Stroke code

History of Present Illness: A man in his mid-70’s with a history of HTN and DM is brought to the hospital for AMS and slurred speech with a LKW time about 12 hours ago.  Medics noted a temp of 102.4 and questionable left arm pronator drift.  He is a poor historian and slow to answer questions but denies pain, nausea, SOB or other complaints.  He does admit to generalized weakness and brain fog.

Vital Signs: Vital signs are normal except for his temperature.

Physical Exam: He is slow to answer questions and seems in a fog.  He has no focal neuro findings but is having trouble cooperating with the neuro exam.  There is no photophobia and jolt sign is negative (if you don’t know what jolt sign is, you should, so please look it up).  Lungs are clear and abdomen is benign.  There is mild bilateral leg edema with symmetric chronic-appearing shin discoloration.

Initial Diagnostic Testing:

  • CBC: normal WBC and other cell counts but there is 88% PMNs as well as toxic granulation noted on WBC morphology (if you don’t know what that means then CLICK HERE)
  • Chem-7: normal
  • UA: normal
  • Imaging: CT brain normal, CXR normal

Given the above data, what is the most likely cause of the AMS and next test/evaluation to obtain?

  • A) CVA; get an MRI
  • B) Meningitis; get an LP
  • C) Cellulitis; check the leg temperature
  • D) UTI; await the urine culture

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWER:

  • A) CVA; get an MRI – unlikely with fever and no focality but I have seen sepsis and stroke present simultaneously
  • B) Meningitis; get and LP – unlikely with no photophobia and negative jolt sign
  • C) Cellulitis; check the leg temperature – CORRECT – common cause of sepsis and may be missed initially, especially in diabetics.  Use the back of your fingers to check skin surface temp on both shins alternating back and forth.  This is more sensitive and specific than appearance, especially early on.
  • D) UTI; await the urine culture – unlikely without pyuria but if there is bacteriuria and no other cause there could still be UTI

CASE CONCLUSION:  left leg was warmer.  A few hours later it was more red.