Thread by @CPSolvers

1/ #Medtwitter, we have a case for you, including a new #IllnessScript from @jackpenner & @EmmaHLevine!

32F presents with fevers, chills, & malaise x 5 days. Pt is somnolent and accompanied by her husband who denies localizing symptoms.

VS T 39C BP 120/60 HR 100 RR 14 100% RA

2/ While the RN is out of the room, the telemetry alarms for V-tach. When the RN returns, the monitor shows sinus rhythm.

Husband reports that the patient appeared to yell out and then was shivering violently for ~2 minutes.

What in this telemetry strip suggests artifact?

3/ You notice that although at quick first glance, the morphology in lead I and II might resemble a wide complex rhythm, lead III shows sinus tachycardia.

Therefore the limb leads I and II are capturing artifact (probably from movement of the patient).

4/ The patient is awake, answers questions, but seems “spacey."

A full set of labs are drawn including blood cultures.
POCT glucose is 120.
VBG pH 7.35 pCO2 46, lactate 10 mmol/L.

Do you have an approach to elevated lactate? Check out this one!

5/ Fluids & antibiotics are ordered
CBC, CMP, & UA - wnl
Blood cultures - in process
CXR clear

45 min later, the patient is more awake but doesn't remember shivering or surrounding events.
Repeat VBG: pH 7.42 pCO2 43 lactate 0.8 mmol/L

What was this "violent shivering" episode?

6/ The patient is found to have urinary incontinence & tongue trauma. CK is 1,750 U/L. Due to the rapid clearance of lactate, elevated CK & post-ictal state, seizure is suspected.

Need a little refresher on generalized tonic clonic seizures? Thank you @EmmaHLevine & @jackpenner!

7/ CT head is neg. MRI head shows multiple lesions, suggesting septic emboli. Blood cultures grow S. Aureus. TTE shows mitral valve vegetation. Patient is diagnosed with S Aureus endocarditis + seizure due to septic emboli encephalitis.

Thanks for following this case with us!