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To Discharge Or Not — Sepsis In The ED Conclusion October 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , trackback
Case Recap: 
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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Case Conclusion:
The 45-year-old man with the urinary tract infection had a SOFA score of 2 and met the Sepsis-3 definition of sepsis, due to pyelonephritis. The patient was convinced to stay in the hospital, had 2 sets of blood cultures drawn, 30 mL/kg of IV fluids administered, and a dose of ceftriaxone 2 grams IV administered. His vital signs remained stable, and the patient was admitted to a monitored hospital bed. He was discharged 2 days later to continue oral antibiotics.
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Congratulations to Rachael Kinuthia, Micelle Jo Haydel, Annie Nunley PA-C, Dennis Allin, and Walter L Novey — this month’s winners of the Emergency Medicine Practice Audio Series Vol IV
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Comments»

1. Kim Perry - October 12, 2018

He could have spent time in an observation status or gone home with scheduled follow up in 24 hours

I would have given him the fluids, Tylenol and ceftriaxone in the ED.

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