Septic Shock in a Psychiatric Patient Is Not Always Just Infection

1Wright Center, Scranton, PA
2Wright Center, Scranton, PA

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 503

Case Presentation:

It is quite challenging to obtain a proper medical history in a patient admitted to a psychiatric unit. At times, the diagnosis in these patients is made purely based on the imaging studies and interventional procedures. We present a case of septic shock due to urinary tract infection (UTI) in a psychiatric patient who also had another medical problem on an imaging study. A 51‐year‐old man with a medical history of learning disability, depression, and anxiety was admitted to the psychiatric unit for worsening depression with suicidal and homicidal thoughts. On the second day of hospitalization, patient was noted to have high‐grade fever, abdominal pain and two episodes of diarrhea and vomiting. Stools were found to be loose, watery and devoid of any blood or mucus. Patient was unable to provide any further history. Physical examination showed temperature 101.4°F and abdomen was soft, nontender with positive bowel sounds. Laboratory data was significant for white blood cell count 20,300/cc, bands 18%, and serum creatinine 1.47 mg/dL. Patient was transferred to medical floor and treatment was initiated as per sepsis protocol for possible clostridium difficile colitis. Patient was empirically started on intravenous levofloxacin and metronidazole. He became hypotensive and more aggressive fluid therapy and eventually ionotropics were initiated after he was transferred to ICU. Blood cultures grew Escherichia coli, and stool was negative for Clostridium difficile toxin. Urine was cloudy and revealed leucocytes and nitrites. Computed Tomography (CT) of the abdomen and pelvis without contrast revealed an 8mm partially obstructing right ureteral stone, right hydronephrosis with perinephric stranding and a “rectal‐catheter”–like foreign body (FB) in the rectum, extending in to the distal sigmoid colon. A stent was urgently placed in the right ureter. Flexible sigmoidoscopy was performed to remove the rectal FB, which was found to be a “toothbrush.” Patient made an uneventful recovery and was eventually transferred back to the psychiatry unit after he was medically stable.

Discussion:

It is always challenging for a hospitalist to obtain proper medical history in patients admitted to psychiatric units. The diagnosis becomes difficult without a proper medical history and this leads to performance of various unnecessary diagnostic tests that may not be cost effective. The history may be obtained from other sources like family members, primary care physician, pharmacy and nurses. A careful physical examination and judicious use of imaging studies may provide a clue to the diagnosis. Our patient, although he had septic shock due to UTI, could not provide any history related to the foreign body in the rectum. An imaging study was helpful in the diagnosis.

Conclusions:

A thorough and careful physical examination and judicious use of diagnostic tests may help to provide a clue to the diagnosis in psychiatric patients. Alternative sources of history must always be sought.

To cite this abstract:

Chintanaboina J, Shrestha S. Septic Shock in a Psychiatric Patient Is Not Always Just Infection. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 503. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/septic-shock-in-a-psychiatric-patient-is-not-always-just-infection/. Accessed April 25, 2019.

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