CEDARLINE MEDICAL CENTER, SACRAMENTO
2100 Halcyon Parkway, Sacramento, CA 95816
Phone: (916) 555-0142 | NPI: 1730345829 | Tax ID: 94-2788907
A41.51 — Sepsis due to Escherichia coli
| ICD-10 | Description |
|---|---|
| R65.21 | Severe sepsis with septic shock |
| N17.9 | Acute kidney failure (AKI on CKD3, resolving) |
| N10 | Acute pyelonephritis (right) |
| N18.3 | Chronic kidney disease, stage 3 (moderate) (pre-existing) |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| I10 | Essential (primary) hypertension |
Ms. Donnelly is a 71-year-old woman with type 2 diabetes mellitus, CKD stage 3 (baseline creatinine 1.3), and hypertension who presented to the Cedarline Medical Center ED via EMS on 04/14/2026 at 19:42 with two days of dysuria and right flank pain, found febrile and confused at home. Initial vitals were notable for T 103.0 F, HR 122, BP 84/48 (MAP 60), RR 24, SpO2 93% on room air, and AAOx2 (GCS 13). Urinalysis demonstrated large leukocyte esterase, positive nitrite, and >100 WBC/hpf; CT abdomen/pelvis was consistent with right acute pyelonephritis. WBC was 18.5 K/uL with 14% bands; procalcitonin 8.2 ng/mL; CRP 201 mg/L. Initial lactate at 19:50 was 3.8 mmol/L. Blood cultures x2 were drawn at 20:05 prior to antibiotics, and ceftriaxone 2 g IV was given at 20:25, within one hour of arrival. A 30 mL/kg Lactated Ringer's bolus (2040 mL) was administered, completed before vasopressor initiation. A repeat lactate at 22:50 was 2.4 mmol/L after the fluid bolus. Despite completion of the full 30 mL/kg crystalloid resuscitation, the patient remained hypotensive with MAP <65, and norepinephrine was initiated at 23:25 via a right internal jugular central venous catheter. She was transferred to the ICU at 23:55. Norepinephrine peaked transiently at 10 mcg/min and was weaned off on 04/15/2026 at 16:25 (approximately 17 hours total). Blood cultures grew Escherichia coli in 2 of 2 sets at approximately 16 hours (bacteremia), pan-susceptible, and the urine culture grew E. coli >100,000 CFU/mL. Creatinine rose from baseline 1.3 to 2.4 at admission and peaked at 2.8 mg/dL on hospital day 2 (04/16) before improving to 1.5 by discharge. The lactate trend was 3.8 -> 2.4 -> 1.6. The patient was de-escalated to the general medicine ward on 04/16/2026 after the vasopressor was discontinued. She was transitioned to oral antibiotics based on susceptibilities and her sensorium and renal function continued to improve. Home antihypertensives and metformin were addressed for outpatient resumption with renal precautions. Home health was arranged.
| HD 1 (04/14 -> 04/15) | ED presentation in septic shock with right pyelonephritis; sepsis bundle completed (cultures, lactate, 30 mL/kg crystalloid, antibiotics within 1h); norepinephrine initiated after fluids; ICU transfer at 23:55. |
| HD 2 (04/15) | ICU Day 1. SOFA max 6. Norepinephrine weaned and discontinued 16:25 (~17 h). Sensorium clearing to AAOx3. Lactate 1.6. E. coli growing in blood and urine. |
| HD 3 (04/16) | Creatinine peaks at 2.8. CVC and Foley removed. De-escalated to general medicine ward. E. coli pan-susceptible confirmed. |
| HD 4 (04/17) | Continued clinical improvement. Transitioned toward oral antibiotics. Home medications addressed with renal dosing. |
| HD 5 / discharge (04/19) | Afebrile >72h, hemodynamically stable off pressors, eating, voiding, ambulating. Creatinine 1.5 (near baseline). WBC 9.8. Discharged home with home health on oral antibiotics at 11:30. |
| Medication | Dose | Route | Frequency | Duration | Indication |
|---|---|---|---|---|---|
| Ciprofloxacin | 500 mg | PO | BID | Complete 14-day total course from 04/14/2026 | E. coli pyelonephritis / bacteremia (pan-susceptible) |
| Metformin | 500 mg | PO | BID | Reduced from home 1000 mg BID pending creatinine recheck at follow-up | T2DM |
| Lisinopril | 10 mg | PO | Daily | Reduced from home 20 mg; uptitrate at follow-up as renal function allows | HTN |
| Amlodipine | 5 mg | PO | Daily | Resume | HTN |
| Atorvastatin | 40 mg | PO | Daily | Resume | Hyperlipidemia / ASCVD risk |
| Provider / Service | When | Reason |
|---|---|---|
| Primary Care Physician — Cedarline Medical Foundation, Adult Medicine | Within 7 days of discharge | Post-hospitalization visit, medication reconciliation, repeat BMP and CBC. |
| Nephrology — Cedarline Medical Group Nephrology | Within 2 weeks | CKD and resolved AKI follow-up; titrate lisinopril and metformin. |
| Home Health (skilled nursing) | First visit within 48 hours | Medication reconciliation, glucose monitoring, safety assessment. |
| Timestamp | 04/19/2026 10:45 | Temp | 98.4 F |
| Heart Rate | 78 | BP | 126/72 |
| RR | 16 | SpO2 | 98% on room air |
| Weight | 67.0 kg | ||