Patient arrives to ED
The patient, a 65-year-old female with a past medical history of coronary artery disease, hypertension and hyperlipidemia, presents with a four-day history of chills, headache, increase in urinary frequency, and left lower quadrant abdominal pain.
One day prior, she was seen at a nearby urgent care where she was diagnosed with a urinary tract infection and started on antibiotics. So far, she has taken three doses of antibiotics. She denies dysuria and denies a prior history of urinary tract infection. She has had two episodes of non-bloody emesis but denies diarrhea or constipation. She denies having fever but has had chills intermittently over the last few days.
She reports her headache started four days ago and describes it as a dull pain that does not improve with Tylenol or ibuprofen.
Initial vital signs are obtained
Temperature: 37.2°C (98.96°F) |Blood pressure: 140/87 |Pulse: 110 BPM |Respiratory rate: 18 | Oxygen Saturation (SpO2): 99% on room air.
Positive physical exam findings were tachycardia and mild tenderness to palpation of the left lower quadrant.
CBC and MDW results come in
CBC results show an elevation in white blood count at 14.7 and an elevated MDW at 26.5.
Antibiotics are ordered
The patient’s elevated CBC and MDW results suggest the possibility of sepsis. Considering the patient’s CBC and MDW results and the patient’s tachycardia and physical exam findings of the left lower quadrant abdominal pain, the physicians order antibiotics.
The physicians also order a CT of the abdomen pelvis at this time.
Chest X-ray results come in
The chest X-ray results show no acute findings.
CMP results come in
CMP (comprehensive metabolic panel) results return normal aside from mild elevation of AST (aspartate aminotransferase) at 72 and ALT (alanine aminotransferase) at 67.
CT abdomen pelvis results come in
CT abdomen pelvis results show moderate to severe bilateral acute pyelonephritis greater on the right side.
Urinalysis results come in
WBC 5 to 10 | RBC 2 to 10 | trace bacteria and squamous cells 20 to 50, suggesting possible infection.
Saving 85 minutes to start antibiotics
Patient vital signs were obtained at 8:53 a.m., and CBC was resulted at 10:24 a.m. and showed elevated WBC along with MDW. This addresses sepsis, which along with the patient's clinical presentation, tipped the scale towards starting antibiotics which were ordered at 10:31 a.m. There were 98 minutes from initial vital signs to antibiotic order.
At 11:56 a.m., the CT finally resulted, which demonstrated bilateral pyelonephritis. If the antibiotics were ordered at the same time when the CT was resulted, it would have been 183 minutes from the time initial vital signs were obtained. By considering elevated MDW as an early sign of sepsis, especially when combined with elevated WBC, physicians saved 85 minutes in ordering antibiotics and further source control.