Publication Date: April 2019 (Volume 21, Number 4)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 04/01/2022.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME and 4 Infectious Disease CME credits, subject to your state and institutional approval.
You are getting close to the end of your busy shift, but you have time to pick up 1 more low-acuity patient triaged with the chief complaint of urinary tract infection. On review of her chart, you note reassuring vital signs, with a blood pressure of 120/63 mm Hg; heart rate of 71 beats/min; respiratory rate of 18 breaths/min; oxygen saturation of 100% on room air; and temperature of 37°C (98.6°F). Nurse triage note states: “Patient presents today with 3 weeks of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by a local urgent care clinic, followed by a full course of ciprofloxacin prescribed by her primary care provider.” When you examine the patient, she claims mild improvement in her symptoms 2 days prior, but now has persistent dysuria again. Initial physical exam is positive only for mild suprapubic discomfort with palpation. Urinalysis is notable for negative pregnancy test, small leukocyte esterase, and negative nitrite. You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering . . .
Just as you are walking out of the first patient’s room, you are called urgently to the room of a 50-year-old man who is agitated, aggressive, and profoundly tachycardic. The patient had been brought in by family for a “psychiatric eval.” His family reports a history of worsening bizarre behaviors, staying up all night, and hallucinations. These symptoms have been worsening over several weeks, but they brought him to the ED tonight after his brother realized that he had not slept in 3 days. The family is unaware of any recent fevers or infectious symptoms. They are also unaware of any recent alcohol or drug use, but his brother notes that he had a “wild” youth. The family is unaware of any history of psychiatric illness. On exam, the patient appears disheveled and is fidgeting frequently. He appears to be responding to internal stimuli. He is oriented to person only and states that he is not sure why his family brought him to the ED. He is able to recall 0 of 3 objects at 5 minutes. He denies recent drug or alcohol use, and there are no track marks visible on his arms. He has an ataxic gait and diminished reflexes in his lower extremities. You decide to pursue further medical evaluation before calling psychiatry. Basic metabolic panel and CBC are unremarkable. A CT scan shows mild atrophy, but no acute findings. You decide to perform a lumbar puncture for evaluation and wonder if there are any specialized tests you should consider…