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A 25-year-old female presents to the emergency department with fever, nausea, vomiting, and flank pain. She has had dysuria for the past 2 days, with progressively worsening flank pain. She has not been able to tolerate oral intake for the past 2 days. She has no prior medical history. On examination, she has a fever of 103.1°F, blood pressure of 85/40, heart rate of 125 bpm, respiratory rate of 24/min, and pulse oximetry of 89% on room air. She appears diaphoretic, tachypneic, and in severe pain. She has crackles at the lung bases bilaterally, and on cardiac examination she is tachycardic but has no murmurs, gallops, or rubs. She has tenderness to palpation of both costovertebral angles. Laboratory evaluation demonstrates WBC of 16,000 cells/mm3. Chest x-ray demonstrates small bibasilar pleural effusions. Urinalysis shows large leukocyte esterase and nitrites, with 50 WBCs/hpf and 10 RBCs/hpf. Additional labs are in process, including an arterial blood gas, serum lactic acid level, liver function tests, urine culture, and blood cultures.

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1. What is the clinical syndrome presented?

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2. What is the next appropriate step in management?

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Answers

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  1. This patient meets criteria for systemic inflammatory response syndrome (SIRS) based on the presence of fever, tachycardia, leukocytosis, and hypoxia, which meets all 4 of the SIRS criteria. Additionally, because the patient has a suspected source of infection, she meets the definition for sepsis. It is not yet known whether she has severe sepsis or septic shock, as there is insufficient detail provided at this point.

  2. The next appropriate step in management is aggressive intravascular volume resuscitation. Additional steps to consider immediately thereafter include ordering appropriately directed laboratory and imaging studies to guide infection source identification, and initiating empiric broad-spectrum antimicrobial therapy. Appropriate consultation and evaluation by the intensive care unit (ICU) medical team may be necessary to help determine if critical care in the ICU is indicated.

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The case provides limited but adequate detail to determine this patient's current clinical status. She is acutely ill based on the presence of signs and symptoms indicative of sepsis. More data will be needed before determining if this patient has severe sepsis or septic shock. Laboratory data may reveal end-organ damage, which would suggest the presence of severe sepsis. Because of hypotension, early and aggressive volume resuscitation in this patient is essential for both therapeutic and diagnostic purposes to determine if septic shock is present. In parallel to treatment, efforts to identify the source of infection should begin based on information obtained from the history and physical examination, along with indicated laboratory testing, imaging studies, and consultation. Close follow-up of the patient's initial clinical course after initiation of therapy marks an important triage step where the clinical decision must be made about level of care needed for this patient. Lack of clinical response to early and aggressive treatments would ...

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