1/ My patient has tachycardia, fevers and lactic acidosis. Does he/she have sepsis? Heffner et. al found that, up to 18% of patients with SIRS, initially diagnosed as sepsis, had a non-septic SIRS also known as "sepsis mimicker". #Tweetorial
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2/ A 30-ish y.o. patient with history of type 1 diabetes mellitus, essential hypertension & asthma presented to the ED with a 2-day history of dry cough. No dyspnea, chest pain, documented fevers, sweats, rhinorrhea or sore throat. Mentions 30-lb wt loss + fatigue last 6 months.
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3/ Patient stopped working due to fatigue. Diabetes is well controlled (A1c 7.5%). Patient smokes cigarettes, drinks socially and denies using drugs. No vaping. On presentation: BP 150/110, HR 134, RR 20, SpO2 98%, Tm 99.5F.
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4/ Few initial thoughts: - Cough is acute (foreground). Wt loss + fatigue are chronic (background). - Is cough the culmination of a chronic disease or a superimposed phenomenon? - Wt loss + decent oral intake suggests calorie expenditure > calorie intake a.k.a. hypermetabolism.
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5/ Quick exam: thin-appearing, does not look sick, tachycardic/regular, CTAB, tender in RUQ of abdomen, no skin rash.
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6/ Initial labs: WBC 8.2, Hgb 13.3, Plts 348, BMP unremarkable, albumin 3.7, protein 9.6, ALP 312, AST 65, ALT 49, bili 0.3, INR 1.2, Ca 10.4, ketones normal, lactic acid 2.9-->3.3-->4.8, ESR 126, CRP 4.3, HIV-, TSH 1.9, UA w/ 2+ protein. Highlights?
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7/ CXR to the left, compared to old one from 2017. Seems overall more hazy. Poorly penetrated by x-rays? No clear alveolar infiltrates. Hilar prominence?pic.twitter.com/qkPeg5TAZg
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8/ Haziness is real indeed. CT shows tree-in-bud and faint ground glass opacities. Mention of reactive hilar and mediastinal lymphadenopathies. Is this septic pneumonia? But how to explain chronic weight loss?
pic.twitter.com/hbwcLir7J9
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would love to see soft tissue windows but those are huge R hilar lymph nodes that seem unlikely to be just reactive.
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