An officer calls down to the medical office stating that Ms. Bradley, a 62-year-old woman, is complaining of feeling lightheaded, tired and weak. You respond to the unit and find Ms. Bradley sitting in a wheelchair with a cup of water in her hand, given to her by the officer. Ms. Bradley states that she has been feeling this way for the last three days, but just stayed on her bunk. Today the officer would not let her do that and called medical. She is awake and alert, but states that she cannot stand up without getting dizzy. She has been adherent to her medication regimen, which includes 2 medications for hypertension. You obtain vital signs, and they are T 102°F, P 106, R 18, O2 sat 94%, BP 88/30. You ask the officer to call medical and alert the provider that you are coming with Ms. Bradley, and immediately transport Ms. Bradley to medical for provider evaluation. When you arrive at medical with Ms. Bradley, the provider is waiting. Vital signs are redone, and they remain basically unchanged. EMS is activated, and the provider completes her assessment of Ms. Bradley.
PROVIDER ACTIONS
Review of Systems
A directed ROS is positive for fatigue, fevers, chills, left-sided flank pain, dysuria, and urinary frequency. Her ROS is negative for headaches, visual disturbances, nasal congestion, sore throat, palpitations, chest pain, abdomen pain, nausea/vomiting, focal weakness or numbness, confusion, weight gain or loss, polyphagia or polydipsia, anxiety, or depression.
Relevant History
The patient’s history is significant for essential hypertension diagnosed at age 52; she denies drug, tobacco, and alcohol use. She reports a family history of hypertension and high cholesterol.
Allergies No known allergies; no known food allergies.
Medications: Hydrochlorothiazide 25 mg PO QD; Amlodipine 5 mg PO QD
Provider Physical Examination
Vitals (repeated in medical): T 102.2°F, P 110, R 2, BP 86/40, HT 5’ 5”, WT 135 lbs, BMI 22.5.
General: Patient is alert and oriented x 4, appears stated age, unable to stand independently without dizziness; needed assistance x 2 to ambulate from the wheelchair to the gurney
Psychiatric: Normal affect, no disorganized behavior.
Skin, Hair, and Nails: No rashes, normal skin turgor, normal hair texture, nails without splinter hemorrhages or clubbing.
Head: Normocephalic, atraumatic, no lesions.
Eyes: PERRL, anicteric sclerae.
ENT/Mouth: Mucous membranes dry, no oral cavity lesions, oropharynx without erythema.
Neck: Normal neck circumference, no thyromegaly.
Chest: No obvious pectus deformity, normal excursion.
Heart: S1, S2, RRR, no murmurs, gallops or rubs.
Lungs: Unlabored respirations, clear to auscultation bilaterally.
Abdomen: Soft, non-tender, to palpation; bowel sounds x 4, normoactive. Musculoskeletal: Left-sided CVA tenderness.
Neurologic: A&O×4, cranial nerves II to XII intact, motor strength 5/5 at the upper extremity and lower extremity bilaterally, no gross sensory deficits.
Differential Diagnoses for Ms. Bradley
Orthostatic hypotension is a possible diagnosis. Elderly patients may be prone to orthostasis caused by medications, fluid or blood loss, or adrenal insufficiency. The patient’s lightheadedness and fatigue may be from orthostatic hypotension, which should especially be considered in patients who are on anti-hypertensives. However, this patient is febrile, which is not a symptom of orthostatic hypotension.
Left renal calculi/pyelonephritis are possibilities. The patient has left-sided CVA tenderness, which can be representative of a renal stone. Some of the symptoms of renal stones may overlap with those of pyelonephritis. Pyelonephritis with concurrent renal calculus presents a complicated diagnostic and treatment challenge.
Sepsis is also a possible diagnosis. She may have a urinary tract infection such as cystitis or left-sided pyelonephritis, which could be the source for sepsis. Further, her symptoms of fatigue, fevers, chills, hypotension, and tachycardia are suggestive of sepsis.
Pneumonia may also present with overall fatigue from an infection. This is not likely given clear breath sounds on exam and no respiratory complaints such as cough and dyspnea on ROS.
Dehydration/electrolyte abnormality may also be a diagnosis for this patient. Weakness and fatigue may be a result of electrolyte imbalance and/or dehydration. The patient has had decreased appetite and oral intake, which can negatively impact hydration status and electrolyte homeostasis. The patient is also on a thiazide diuretic that may potentially cause dehydration and electrolyte aberrations.
Polypharmacy is a possibility. Sometimes a patient’s symptoms such as fatigue and dizziness may be a result of medications. This patient is on two anti-hypertensives, so it is less likely that two medications alone would be a cause for her symptoms, especially if she has been on these medications chronically. Also, the patient’s febrile status excludes the diagnosis.
Most Likely Diagnosis: Sepsis
This patient presents with signs and symptoms consistent with sepsis. The presence of an infection and her symptoms of fatigue prompts serious consideration of sepsis as the diagnosis.
Sepsis is a systemic reaction caused by an infectious agent that initiates a cascade of events leading to fever, tachycardia, tachypnea, and leukocytosis or leukopenia. The immune system releases inflammatory mediators such as interleukins and cytokines in response to an infection. Cytokines cause blood vessels to dilate and increase capillary permeability to promote blood flow, which in turn allows more immune system cells to reach an area to fight infection. The secondary effect of vasodilation causes hypotension, which causes organ hypoperfusion and can lead to organ damage. In this case, Ms. Byrd developed Acute Kidney Injury which, in conjunction with her decreased fluid intake and her taking her anti-hypertensive medication caused more severe hypotension.
Diagnostic Tests/Imaging
Because the patient was being sent out immediately to the emergency department, no diagnostic tests were obtained at the facility. Nursing staff did initiate intravenous access and began administration of NS while awaiting EMS. They also continually monitored Ms. Bradley.
Treatment Approach
Sepsis is an infection that has elicited a systemic inflammatory response. The systemic inflammatory response syndrome (SIRS) is based on the following criteria (at least two are needed): Fever > 38°C or < 36°C, HR > 90, RR > 20, WBC > 12,000 or < 4000. Clinically, systemic inflammatory response syndrome is identified when the patient exhibits two or more symptoms including fever or hypothermia, tachycardia, tachypnea, and change in blood leukocyte count.
Mortality is reduced when broad-spectrum antimicrobials are initiated as early as possible, making prompt diagnosis critical. Patients with severe sepsis and septic shock who experience a delay in the first antibiotic administration are associated with increased in-hospital mortality.
AT THE HOSPITAL
At the hospital, a CBC (to rule out infection, screen for anemia and malignancy), CMP (to evaluate electrolytes, glucose, and kidney functions), thyroid function, troponin (rule out myocardial infarction), lactic acid, and urinalysis (to rule out infection) were obtained. Urine and blood cultures were also sent to the lab. In addition, an EKG was performed.
Results
CBC – WBC 14,000; Hgb 13.4 g/dL PLT 300,000
CMP – Sodium 135; Potassium 4.5; BUN 15; Creatinine 1.4; Glucose 100; Chloride 97; CO2 25 Urine dip – Cloudy appearing urine, positive leukocyte esterase, positive nitrites, negative ketones
TSH 0.85; T4 90; T3 150
Troponin 0.03
Lactic acid 1.2
Blood cultures were negative (resulted 1 day later, finalized 2 days later)
Urine culture gram-negative rods (resulted one day later as preliminary result), Escherichia coli (resulted 2 days later as final result)
EKG sinus tachycardia
Ms. Bradley was diagnosed with sepsis secondary to pyelonephritis and required a 5-day hospital stay for treatment. She was discharged to the facility on oral antibiotics.
She was seen daily by nursing staff, and at her 1-week post hospitalization provider follow-up was noted to be doing well. Her repeat labs were within expected parameters.
Upon arrival back at the facility after her hospital discharge, Ms. Bradley was seen daily by nursing staff, and at her 1-week post hospitalization provider follow-up was noted to be doing well. Her repeat labs were within expected parameters.
PATIENT EDUCATION TOPICS
Sepsis and septic shock – etiology, treatment and red flags to report to healthcare staff
Urinary tract infection (cystitis and pyelonephritis) – etiology, treatment and red flags to report to health care staff
Medication ordered, potential adverse effects
Self-care
TREATMENT APPROACH
Sepsis is an infection that has elicited a systemic inflammatory response. The systemic inflammatory response syndrome (SIRS) is based on the following criteria (at least two are needed): Fever > 38°C or < 36°C, HR > 90, RR > 20, WBC > 12,000 or < 4000. Clinically, systemic inflammatory response syndrome is identified when the patient exhibits two or more symptoms including fever or hypothermia, tachycardia, tachypnea, and change in blood leukocyte count.
Mortality is reduced when broad-spectrum antimicrobials are initiated as early as possible, making prompt diagnosis critical. Patients with severe sepsis and septic shock who experience a delay in the first antibiotic administration are associated with increased in-hospital mortality.
REFERENCES
Comstedt P, Storgaard M, Lassen AT. The Systemic Inflammatory Response Syndrome (SIRS) in acutely hospitalised medical patients: a cohort study. Scand J Trauma Resusc Emerg Med. 2009;17:67. doi:10.1186/1757-7241-17-67
Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotics treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42(8):1749–1745. doi:10.1097/ccm.0000000000000330
Jacobi J. Pathophysiology of sepsis. Am J Health Syst Pharm. February 1, 2002;59(1):S3–S8. doi:10.1093/ajhp/59.suppl_1.s3
Scheer CS, Fuchs C, Gründling M, et al. Impact of antibiotic administration on blood culture positivity at the beginning of sepsis: a prospective clinical cohort study. Clin Microbiol Infect. March 2019;25(3):326–331. doi:10.1016/j.cmi.2018.05.016
Wijesinghe, Sampath. (2021). 101 Primary care case studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
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