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 of yesterday evening. Medics noted a temp of 102.4 and mild 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 & Physical Exam:
Vital signs are normal except for his temperature. 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 look it up).
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 & lipase: normal
- UA: normal
- Imaging: CT normal, CXR normal
What is the most likely cause of the AMS and next test/evaluation to obtain?
- A) CVA; get an MRI
- B) Meningitis; get and LP
- C) Cellulitis; check the leg temperature
- D) UTI; await the urine culture
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>
****************************************************************************
THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
Emergency Medicine 1-Minute Consult, 5th edition
A-to-Z EM Pharmacopoeia & Antibiotic Guide, NEW 5th edition
8-in-1 Emergency Department Quick Reference, NEW 5th edition
******************************************************************************
<<<<<<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>>>>>>>
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 bacteriuria it could be.
CASE CONCLUSION: left leg was warmer. A few hours later it was more red.
