Thursday, July 20, 2006

A Textbook Patient: Sepsis

Category: Clinical Rotations

Isn't it great when patients follow all the rules? And by that I don't mean patient compliance, like taking their medicine properly or quitting smoking or following a good diet. I mean when their disease process presents in a classic textbook fashion. Take today for example....

Our patient in the ER was a 21 year old female with left flank pain, back pain, vomiting and fever. No interesting past medical history except for a couple previous bladder infections and some ovarian cysts that weren't really givng her a problem. No surgical history at all, no medicines, no allergies.

Criteria for SIRS (Systemic Inflammatory Response Syndrome)
(1) Temperature >38 C or <36>
(2) heart rate > 90
(3) Respiratory rate > 20 or PaCO2 <>
(4) WBC count > 12,000 or <> 10% bands

If a patient meets any two of the above criteria, they have SIRS. Sepsis is SIRS plus a documented source of infection, usually bacterial. Our patient had:

1) Temperature of 38.6 C
(2) Heart rate of 136
(3) Respiratory rate of 24
(4) WBC count of 17,000

So not only did she meet all four criteria for SIRS, her urine came back all nasty and positive for infection, thus putting her in the sepsis category.

Now why can't all our patients be that way? It was extremely satisfying to watch all those factors neatly come into place and to see the diagnosis fall gently out of the sky and into our hands with such little effort.

But isn't there more to doctoring than that? Of course there is. The real challenge, the real test of a diagnostician is when patients bodies' do not read the textbooks. It's when patients present with all the symptoms of a certain illness, but their actual illness is something else, manifesting in an unusual way, causing physicians to go down bunny trails, misdiagnose, pull their hair out, frantically consult various specialists, and maybe even get sued.

A patient like today's is certainly gratifying, and I'm glad I can spot the obvious. That's step one. Step two is to have the ability to look beyond the normal, to spot the not-so-obvious, to think outside the box and (gasp) be creative. I hope that somehow I'm developing that ability as I bumble along.


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