Individual Case Study Analysis

Mr. X is an 88-year-old Caucasian male with history of stage 4 renal cell carcinoma s/p right nephrectomy, CKD stage 2, nephrolithiasis s/p left ureteral stent insertion developed fever, chills, tachycardia, and tachypnea.

EMS was called to the patient’s home by his son after Mr. X started feeling faint and disoriented.  Upon their arrival at the ER, Mr. X’s temperature has reached 39.2ºC. He was flushed and ill-appearing, with a pulse of 121 and a blood pressure of 90/55 mm Hg.

Physical inspection revealed a lethargic, flushed, slightly confused elderly man. He was admitted to the hospital for urosepsis complicated by septic shock.

Physical exams: 

Temperature: 39.5C

CV: HR 121bpm. BP 90/55 mm Hg (MAP 66). Continuous cardiac monitoring shows a-fib with ventricular rate in the 100s (chronic condition). Irregularly irregular rate and rhythm. No murmur. Peripherial bounding pulses

Respiratory: RR 38 breaths per minute. Equal air entry bilaterally. No wheezing or crackles. Chest is resonant on percussion

Skin: Skin warm, flushed with no jaundice.

GU: Foley catheter in place with cloudy hematuria and sediment. Ulceration to urethral meatus. UOP approximately 0.1 mL/kg/hr.(normal1.5-2 ml/kg/hr)

Extremities: warm with bounding pulses

Laboratory evaluation shows

· WBC count of 18,575/microliter with differential 75 segs, 9 bands, 16 lymphs, and 6 monos,

· Hct 45.2% 

· BUN of 50 mg/dL

· Creatinine of 5.5 mg/dL

· Potassium of 5 MEq/L

· Serum Sodium of 149 mEq/L.

· D-dimer of 570 ng/mL

· Glucose of 160 mg/dl

· Serum osmolarity 325 mOsmol/L

· Serum lactate 4.5 mmol/L

Arterial Blood Gases (on room air): pH 7.31, paO2 100 mmHg, paCO2 30 mmHg, HCO3 14 mmol/L

Blood Culture: 3 of 3 sets (+) E. coli. P. aeruginosa.