On 7/30/25, this 53-year-old woman with a past history of TIA presented to the ED with triage complaints that included nausea for several days, lower back pain (6/10, “cramping”), and numbness/tingling to the right leg beginning around 1800, with fever and tachycardia at triage (T 101.3°F, P 114, BP 129/78, SpO₂ 96%). The treating ED physician’s note, however, does not meaningfully address the triage-documented nausea/back pain/right-sided sensory symptoms; instead, the HPI reframes the presentation as shaking chills and myalgias starting that day with only “mild nausea” described as chronic/medication-related, and denies urinary symptoms. The documented exam is described as unremarkable and the differential focuses on absence of meningeal signs and lack of respiratory or abdominal findings rather than reconciling the recorded back pain and focal neurologic complaint.
The objective data from the 7/30 visit show a systemic inflammatory picture that was not trivial: WBC 13 with fever and tachycardia, mild hyponatremia (Na 131), low CO₂ (20), creatinine 1.30, low magnesium (1.5), albumin 3.0, and an EPIC Sepsis Risk score of 7.64. She received acetaminophen and a liter of LR with improvement in vitals, and CXR was negative. Urinalysis showed trace leukocyte esterase and trace blood (with no “obvious infection” noted), and a viral/atypical panel and urine culture were obtained but were pending at discharge; the viral panel later resulted negative and the urine culture later grew E. coli.
The discharge impression documented “viral syndrome,” largely based on a “negative workup” and normal lactate (1.6), with no clear documentation of (a) risk stratification for urinary source in a febrile patient with back pain or (b) how pending culture results would be tracked and acted upon. No head/ABD CT/other imaging was performed outside of the CXR.
She returned on 8/1/25 in septic shock and imaging identified a 14 mm obstructing stone at the right UPJ with moderate hydronephrosis/nephromegaly, and urology documentation characterizes the 7/30 urine as “unremarkable” but specifically notes that no imaging was completed on 7/30 and that the 7/30 culture later showed E. coli. Emergent urologic decompression was required, and thick/purulent urine was described at the time of stenting.
During this hospitalization she was also diagnosed with ischemic stroke (MRI describing acute/early subacute infarct; later documentation referencing right PCA occlusion), and neurology documentation includes statements consistent with sepsis-related mechanisms (“suspect hypercoagulable state with underlying sepsis event”) while also acknowledging they “cannot rule out hypoperfusion from hypotension/septic shock.” The chart also notes visual symptoms reported since 7/30, which may complicate precise timing of stroke onset relative to the septic shock episode, but the record supports at least a plausible contribution/worsening pathway through sepsis-related hypercoagulability and/or hypotensive hypoperfusion.
For an ED standard-of-care and causation assessment, the key questions are:
(1) whether the 7/30 presentation (fever + tachycardia + leukocytosis + back pain) should have triggered a higher index of suspicion for urinary source and obstructing stone/upper tract infection despite a relatively non-diagnostic UA
(2) whether renal imaging (CT/US) or alternative urinary source evaluation was indicated prior to discharge given the subsequent finding of an obstructing UPJ stone with hydronephrosis
(3) whether discharge was appropriate with pending urine culture in this clinical context and what the expected “culture callback” process should have been
(4) whether the missed/delayed diagnosis and treatment of infected obstruction more likely than not led to progression to septic shock.
IP continues to have multiple deficits related to the stroke episode.
Thank you in advance.
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Do you believe there might have been medical error?
It was clearly a missed stone, and with that presentation, more likely should have been done in terms of workup.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the diagnosis was missed, it led to the sequela described.
What makes you a good expert for this case?
I am a full time practicing Emergency Medicine physician, with over 13 years of experience. I work in a busy (>75,000 annual visits) emergency department. I am board certified in Emergency Medicine and am comfortable opining on the standard of care and causation as it applies to Emergency Medicine. I also have over 5 years of experience in the medical legal space, and work with both plaintiff and defense attorneys to form opinions based on the facts of a case. Thank you for your consideration.
How often do you encounter cases similar to this one in your practice?
I evaluate cases of UTI, pyelonephritis and renal colic daily to weekly
Do you believe there might have been medical error?
The patient presented febrile and tachycardic. Triage documentation specifically noted lower back pain (6/10, cramping) and numbness/tingling of the right leg. However, the ED physician’s note does not explicitly reference back pain, potentially attributing symptoms to generalized myalgias, nor does it address the unilateral lower-extremity neurologic complaints documented at triage. Triage documentation should be reviewed and reconciled with the provider note. In this case, it included lower back pain and right-sided numbness/tingling, findings that warrant further consideration. Laboratory studies demonstrated leukocytosis and an elevated creatinine of 1.30, which should be interpreted in the context of prior baseline renal function. Urinalysis reportedly showed trace leukocyte esterase and trace blood; however, it is unclear whether this represented a urine dipstick alone or a full microscopic urinalysis was also performed. Key elements such as white blood cells, bacteria, nitrites, epithelial cells, and red blood cells which are obtained from a urinalysis are not reported. In the setting of an abnormal urine dipstick and a urine culture being obtained, a formal urinalysis would typically be expected. The absence of this information raises the possibility that only a dipstick was performed. On the patient’s subsequent presentation, imaging revealed a large right-sided ureteropelvic junction (UPJ) stone with associated hydronephrosis. Culture data reportedly confirmed E. coli, and urologic documentation describing thick or purulent urine further supports the diagnosis of a urinary tract infection in the setting of an obstructing stone. This constellation of findings is consistent with an infected obstructive uropathy as the underlying cause of the patient’s septic shock. Addressing the specific questions: Should the initial presentation have triggered a higher index of suspicion for a urinary source and possible obstructing stone or upper UTI despite a non-diagnostic UA? Likely yes. The reported urine dipstick findings are equivocal, and in this clinical context should have prompted a formal urinalysis. While patients with obstructing ureteral stones often present with severe, colicky pain and inability to remain still, this classic presentation may be blunted in certain populations (e.g., older patients or those with altered sensorium). Based on the information available, the patient may not have exhibited classic renal colic, which could reasonably lower, but not eliminate, the ED provider’s suspicion and may partially explain why CT imaging of the abdomen and pelvis was not initially obtained. Was renal or other imaging indicated prior to discharge, given the subsequent findings? Based on the triage documentation, the combination of fever, back pain, and unilateral lower-extremity neurologic symptoms should have prompted consideration of imaging. This presentation can raise concern for urinary pathology but also for spinal infection, such as epidural abscess or discitis, particularly in patients at increased risk for bacteremia. Additionally, hematuria on urinalysis, even if minimal, should raise suspicion for nephrolithiasis in the right setting and may further support obtaining CT imaging of the abdomen and pelvis. Given the symptoms documented at triage, imaging was likely indicated. Did the missed or delayed diagnosis and treatment of an infected obstructing ureteral stone more likely than not contribute to the progression to septic shock? Yes, more likely than not. Infected obstructive uropathy is a well-recognized urologic emergency, and delays in diagnosis and source control are associated with rapid clinical deterioration and progression to septic shock.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is more likely than not that delayed recognition and treatment of an infected obstructing ureteral stone contributed to the patient’s progression to septic shock. The initial presentation included fever, tachycardia, back pain, and abnormal urine findings, which should have raised concern for a urinary source and prompted further evaluation. The subsequent discovery of hydronephrosis, positive E. coli cultures, and purulent urine confirms an infected obstructed system, a known urologic emergency in which delayed diagnosis and source control are associated with rapid progression to septic shock.
What makes you a good expert for this case?
I am well qualified to serve as an expert in this case based on my clinical and operational expertise in sepsis care. I am a board-certified emergency medicine physician and serve as the Emergency Department Director of Sepsis Care for a large academic health system, where I routinely conduct detailed chart-level reviews of sepsis cases, including delayed recognition, source identification, imaging decisions, and antibiotic timing. I regularly provide feedback and education to emergency physicians and advanced practice providers on sepsis standards of care. This role, combined with my active clinical practice and research experience in sepsis diagnostics, allows me to evaluate this case objectively and in alignment with current emergency medicine practice standards.
How often do you encounter cases similar to this one in your practice?
I encounter cases similar to this one frequently in my practice. Given my role as Emergency Department Director of Sepsis Care, I regularly review and manage sepsis cases in the ED, including presentations involving delayed recognition, atypical symptoms, and evolving sources of infection.
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