by Florian M.E. Wagenlehner, Kurt G. Naber Urology Clinic, St. Elisabeth Hospital, Straubing, Germany
The case A 71-year-old woman was referred to the Internal Medicine emergency room on April 14th . The accompanying husband explained that she suddenly became confused during the night and later turned somnolent. Her recent clinical history was uneventful, except for an episode of lower abdominal pain 4 days previously, which improved after scopolamine butylbromide. She had experienced similar symptoms 3 months earlier and was fully asymptomatic in between. The physical examination showed a confused patient, with a heart rate of 128/min (atrial fibrillation at ECG), low-grade fever (37.8°C), normal auscultation of the lung and abdominal findings, no costovertebral tenderness, no skin abnormalities, no meningism or focal neurological signs. The patient was admitted to the Intensive Therapy Unit with the tentative diagnosis of apoplexy, atrial fibrillation and fever of unknown origin. Blood and imaging tests, including cerebral CT scan, are reported in table I. Three days later, while afebrile, she developed an episode of acute psychosis in the absence of meningism or focal neurological signs; she was then transferred to an external psychiatric clinic. However, the following day she developed high fever, up to 41°C, with chills; cerebral CT scan was repeated and was again normal. She was transferred to the Neurological Clinic with the tentative diagnosis of meningo-encephalitis: meningism was present, focal neurological signs were absent. Further blood tests are reported in table I.
Question 1) - What important test to discover the cause of sepsis is missing? (Only ONE answer is correct)