'What's the cause of the paralysis?' I ask as I lift her shirt to reveal her abdomen.
No abdominal distention or ascites.
*I place my hands and palpate her abdomen.*
Soft. Non-tender, and no masses. Kidneys are not palpable.
*I find her pubic bone and press down just above it.*
No bladder distention or pain when pressing on the bladder.
'When was the last time she changed her catheter?' I ask as I start to move down to the groin area.
'Ok Aubrey, I'm just going to check your catheter, okay?'
*I follow her catheter to its insertion point*
No erythema or discharge around the urethra.
'Temp is 39' the nurse lets out as she places the thermometer down and starts getting ready to draw blood.
'Does she have any medical problems? Allergies? Surgeries?' I ask Dunne.
'Is she up to date on immunizations? Do you know by chance?' I ask
*I grab her left leg, the one closest to me, and flex her hip to 90 degrees.*
Her leg is atrophied and flaccid, but that's not surprising since she's been paralyzed for so long.
*With her hip and leg flexed to 90 degree's I begin extending her lower leg, straightening her knee. Nothing happens. She does not lift her head off the bed or complain of pain in her neck.*
Negative Kernig sign. Probably not meningitis.
'This may be a bit of a personal question, but do you know if there is any possibility she might be pregnant?' I ask.
This might seem like an odd question to ask, but it's important. Just because she's paralyzed doesn't mean a girl in otherwise perfect reproductive health can't be pregnant. It happens, and I need to know because it will dictate exactly what medications I give and what testing I run.
'Well what I'm seeing points really strongly towards an upper urinary tract infection, particularly an infection in her kidneys that's gone systemic. I'm going to check her blood and urine to confirm and see if I can figure out exactly what bacteria is causing this. Until then I'm going to put her on an antibiotic immediately and we're going to swap out that foley, since it's likely the source of the infection.'
*I pause for a second*
'She seems to be responding to fluids, but she's still septic. So for sure I'm going to admit her. Pending on the results, I'm going to confer with the internist who's taking her in and see if we want to do an abdominal CT to check her kidneys for an abscess, but we probably won't right away. Usually we try and treat the infection and if it doesn't go away within a few days then we image and check for an abscess.
She's in pretty serious shape but she has youth on her side, so I think we'll get her going in the right direction.'
*I pause again*
'One thing I need to explain is that once we start giving antibiotics, her condition may actually get a littler worse before it gets better. Once the bacteria that's circulating around her blood right now starts dying from the antibiotic, they release a bunch of bacterial junk, which can cause the immune system to overreact a bit. So there is always a risk of further deterioration once we start the antibiotics. So is it okay if we start the antibiotic therapy?'
'Do you have any questions or is there anything I can do for you right now?' I ask.
'Oh and your name is?' I ask Dunne. I shake his hand: 'I'm Dr. Chris Grant.'
'Well, sorry we had to meet under these circumstances but I think she'll be back in no time once we get these antibiotics going.' I say.
As I go to leave the room I look at the nurse.
'Lets keep her going on fluids and lets start Gentamicin. I'll enter it in right now' I tell her. She acknowledges and I leave the room, stoping at the first computer I encounter.
*I type up my assessment and enter my orders:*
CBC, serum Electrolytes, kidney function, venous blood gas, lactate, bHCG level. Urine analysis, culture, Leukocyte esterase, and nitrites. Remove and replace foley. IV Gentamicin, Normal saline.
'It's most likely a gram negative, probably E.Coli. Using Ceftriaxone would have been nice, but I'm not willing to risk an allergic reaction, despite the chance being pretty low.' I think to myself as I enter the order. 'Gentamicin will do instead.'
*I enter the order and log out*