35 yo female with UTI

[pbruss]

another weird case i just saw at Lima.

35 yo female come in by EMS because she feels "sick". she comes into the ER often for pain complaints, is well know by all the staff, and has a history of drug abuse including IV heroin. she was seen in the ER 2 days ago for similar vague complaints, had a normal BC and BMP, and a UA that showed nitrite positive bacteria with WBCs and leuks. she had a warrant out for her arrest so she was discharged from the ER to jail in law enforcement custody with a script for bactrim. she was in jail for 24 hours and says they "took her scripts from her" so she never got them filled. she left jail and went home for about 12 hours before calling EMS.

she is alert and oriented but is intentionally a very bad historian and denies any drug or alcohol use after leaving the jail. when you talk to her she interrupts you every 15 seconds asking for "something for my pain" and "am I going to stay in the hospital"? she does report the following symptoms: nausea and vomiting, fatigue, diffuse weakness, blurred vision, fatigue, and body aches which she did not have on her first visit.

Exam

p- 112, bp -125/74, r -30, t- 37, 98% on RA
AAOx3 alert and interactive, no acute distress
CV- tachycardia, RRR, no MRG
Lungs- tachynepic but speaks comfortably in full sentences. CTA bilat.
ABD- moderate diffuse tenderness, soft, normal BS, no guarding or rebound.
ext- 2+ pulses, cap refill 5 sec, no clubbing, cyanosis, edema, or rash

you obtain the following labs:

ABG- ph 7.2, Pco2 35, Po2 90 

Na-149
K- 4
CL-85
CO2-28
BUN- 35
Cr- 1
Glu- 98

Etoh- 0

You go back in the room to try and talk to the patient again and you see her frustrated nurse who has extra vials of blood, urine, sputum, vomit, and stool all from the patient.


Based on the limited history, PE, and labs above which of the following bedside tools within the ER will most likely give the diagnosis?

A. slit lamp
B. woods lamp
C. tono-pen
D. stryker
E. ultrasound
F. tuning fork

[kemple]

The picture I see painted relates to dehydration secondary to urosepsis or pylo. She is acidotic, tachycardic, tachypnic (most likely 2/2 metabolic acidosis), and has nausea/vomiting with known UTI which could lead to those. I would definitely want a UPreg and CBC, as for the vision and weakness you would be hard pressed to not do an LP especially w hx of IVDA. I would think slit lamp for increased ICP by checking cup:disk ratio might help with that.

[pbruss]

Good reasoning, but you could also use the tono pen and ultrasound to eval for elevated ICP. Increased IOP does correlate with increased ICP in the acccute setting and you can measure the diameter of the optic nerve with the vascular probe to tell if the ICP is up.

[kemple]

F tuning fork for ASA OD? Tachypnic, acidotic, no other good cause.

[pbruss]

Even though she denies it, everything looks like she took something to make herself sick to avoid law enforcement and get pain meds. There is a way to tell what she took using one of the answers. Would it help if after we found out what it was we ordered a serum osmolality and it was 329?

[Bjs04f]

she drink some methanol, slit lamp her

[pbruss]

you are on the right track but that is not it. on a side note what you you look for on the slit lamp to indicate methanol ingestion?

[tbarkley]

I would use the ultrasound machine...So this might be far fetched but I think you will see disc cupping and optic atrophy with methanol ingestion.
Did she ingest pruno? I read a case in annuals of EM where there was pruno ingestion and exposure to botulism. Had very similar complaints with blurry vision, difficulty breathing and weakness.


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[Bjs04f]

methanol they talk about cherry red macula, but since its a high osmolar fluid you could see distortion of the chambers due to swelling.

[pbruss]

well done, but it was not methanol.

[Bjs04f]

All right weve got nonspecific symptoms and osmolar gap with acidosis. So methanol, isopropyl alcohol, ethylene glycol, acetone top my list. Great tox lecture recently said just tube them and figure it out later, so lets do that. If we have urine woods lamp it, see if it glows for ethylene glycol byproducts

[pbruss]

EXACTLY. She drank antifreeze after leaving jail to make herself sick to avoid law enforcement and get pain meds. Nice work!