Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Systematic Secondary Survey Reveals Occult Pathology

Patient Demographics

  • Age: 72 years
  • Sex: Female
  • Occupation: Retired teacher

Chief Complaint

"I'm just so weak, I can barely stand up."

History of Present Illness

A 72-year-old woman is brought by her daughter for progressive weakness over 3 days. She has been unable to care for herself and has had poor oral intake. Daughter notes patient has been "confused" and not acting like herself.

Initial Assessment

ESI Level: 2 - High-risk situation requiring urgent evaluation

First Impression:

  • Appearance: Frail, lethargic, responds slowly
  • Work of breathing: Normal respiratory effort
  • Circulation: Pale skin, dry mucous membranes

Vital Signs:

  • Heart rate: 102 bpm, regular
  • Blood pressure: 92/58 mmHg
  • Respiratory rate: 22 breaths/min
  • SpO2: 94% on room air
  • Temperature: 38.4C (101.1F)
  • GCS: 14 (E4V4M6)

Primary Survey

Airway: Patent, speaking in sentences Breathing: Tachypneic but no distress, lungs with crackles at right base Circulation: Tachycardic, weak peripheral pulses, dry mucous membranes Disability: Oriented to person only, no focal deficits, glucose 168 Exposure: No rashes, skin turgor decreased

Secondary Survey

SAMPLE History:

  • Symptoms: Weakness, confusion, decreased appetite, "burning with urination" 5 days ago
  • Allergies: Penicillin (rash)
  • Medications: Amlodipine, atorvastatin, metformin
  • PMH: HTN, hyperlipidemia, type 2 DM
  • Last Meal: "A few bites" yesterday
  • Events: Progressive decline over several days

OPQRST for Weakness:

  • Onset: Gradual, 3-4 days
  • Provocation: Worse with standing
  • Quality: Generalized, "no energy"
  • Radiation: N/A
  • Severity: Unable to perform ADLs
  • Timing: Progressive

Comprehensive Physical Examination:

Head/Neck:

  • No meningismus
  • No JVD
  • Dry mucous membranes

Cardiovascular:

  • Tachycardic, regular
  • No murmurs
  • Weak peripheral pulses

Pulmonary:

  • Crackles at right base
  • No wheezes

Abdominal:

  • Soft, mild suprapubic tenderness
  • No guarding or rebound
  • Normoactive bowel sounds

Genitourinary:

  • Foley placed - cloudy, foul-smelling urine

Extremities:

  • No edema
  • Decreased skin turgor

Neurological:

  • Oriented x1 (baseline per daughter: fully oriented)
  • No focal deficits
  • Moving all extremities symmetrically

Differential Diagnosis (VITAMINS Approach)

  • Vascular: Unlikely given gradual onset
  • Infectious: UTI progressing to urosepsis - HIGH SUSPICION
  • Toxic/Metabolic: Dehydration, electrolyte abnormality
  • Autoimmune: Less likely
  • Metabolic: DKA, HHS possible
  • Iatrogenic: Medication effect
  • Neoplastic: Less likely for acute presentation
  • Seizure: No witnessed seizure activity

Diagnostic Testing

Point-of-Care:

  • Lactate: 4.1 mmol/L (elevated)
  • Glucose: 168 mg/dL

Urinalysis:

  • Positive leukocyte esterase
  • Positive nitrites
  • >100 WBC/hpf
  • Bacteria present

Labs:

  • WBC: 18.2 with 88% neutrophils, 12% bands
  • Cr: 2.1 (baseline 0.9)
  • BUN: 42
  • Na: 131, K: 5.4

Imaging:

  • Chest X-ray: Right lower lobe infiltrate (aspiration vs. early pneumonia)
  • CT Abdomen/Pelvis: Pyelonephritis changes, no abscess

Diagnosis

Sepsis secondary to complicated urinary tract infection (pyelonephritis) with:

  • Acute kidney injury
  • Possible aspiration pneumonia
  • Altered mental status (septic encephalopathy)

Management

Hour-1 Bundle:

  1. Lactate: 4.1 (remeasure in 2-4 hours)
  2. Blood cultures x2 drawn before antibiotics
  3. Broad-spectrum antibiotics: Ceftriaxone 2g IV + Azithromycin 500mg IV
  4. 30 mL/kg crystalloid bolus (1.5L for 50kg patient)
  5. Reassess perfusion status

Response to Resuscitation:

  • After 2L NS: BP 108/68, HR 88
  • Repeat lactate: 2.8 mmol/L (improving)
  • Mental status improving

Disposition:

  • Admitted to medical floor with sepsis protocol
  • Continued antibiotics, hydration
  • Daily reassessment

Teaching Points

  1. Atypical presentations in elderly: Weakness and confusion may be the only signs of serious infection
  2. Secondary survey thoroughness: Suprapubic tenderness and UA findings identified the source
  3. Sepsis recognition: qSOFA score (altered mental status, tachypnea, hypotension) prompted sepsis bundle
  4. Response to resuscitation: Improvement in vital signs and lactate indicated adequate initial resuscitation
  5. Disposition based on trajectory: Clinical improvement allowed floor admission vs. ICU

Clinical Image

Image Description: Portable chest radiograph demonstrating a right lower lobe infiltrate consistent with pneumonia, likely aspiration-related in setting of altered mental status.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/right-lower-lobe-pneumonia

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