CEDARLINE MEDICAL CENTER, SACRAMENTO
2100 Halcyon Parkway, Sacramento, CA 95816
Phone: (916) 555-0142 | NPI: 1730345829 | Tax ID: 94-2788907
Two days of dysuria and right flank pain; found febrile and confused at home.
Ms. Donnelly is a 71-year-old woman with type 2 diabetes mellitus (last A1c 8.1%), chronic kidney disease stage 3 (baseline creatinine 1.3 mg/dL), and essential hypertension, brought to the Cedarline Medical Center ED by EMS after her husband found her febrile and confused at home this evening. Per the husband, she has reported burning with urination and right-sided flank pain for approximately two days, with progressive fatigue, poor oral intake, and rigors today. This afternoon she became increasingly drowsy and was answering questions inappropriately, prompting a 911 call. On EMS assessment at home she was febrile, tachycardic, and hypotensive; a peripheral IV was placed and 250 mL of normal saline was infused en route. On ED arrival at 19:42 she was triaged ESI-2. She denies cough, dyspnea, chest pain, headache, abdominal pain other than the flank discomfort, nausea, vomiting, diarrhea, recent travel, sick contacts, or indwelling urinary catheter. No known drug allergies. Home medications were reconciled with her husband at the bedside.
NKDA (no known drug allergies).
Lives with husband. Works part-time as an office administrator at Sierra Pacific Properties (covered under her active employer group health plan). Never smoker. Rare alcohol. No illicit drug use.
Mother: type 2 diabetes. Father: hypertension, coronary artery disease.
| Constitutional | Subjective fever, rigors, fatigue, decreased oral intake. |
| Heent | No sore throat, no neck stiffness, no visual changes. |
| Cardiac | No chest pain, no palpitations. |
| Respiratory | No cough, no shortness of breath. |
| Gi | No abdominal pain (aside from flank), no nausea, no vomiting, no diarrhea. |
| Gu | Dysuria and urinary frequency x2 days; right flank pain; no gross hematuria reported. |
| Neuro | Acutely altered per family; no focal deficits by available history. |
| Musculoskeletal | Denies trauma or falls. |
| Skin | No rash noted. |
| Parameter | Value |
|---|---|
| Timestamp | 04/14/2026 19:46 (ED triage) |
| Temperature | 103.0 F (39.4 C) |
| Heart Rate | 122 bpm (sinus tachycardia) |
| Blood Pressure | 84/48 mmHg (MAP 60) |
| Respiratory Rate | 24 / min |
| SpO2 | 93% on room air |
| Weight / Height | 68 kg / 163 cm |
| General Appearance | Elderly woman, flushed, diaphoretic, appears acutely ill, responsive to voice. |
| Mental Status | AAOx2 (oriented to person and place; not to time). Follows simple commands. GCS 13 (E4 V4 M5). No focal neurologic deficit. |
| HEENT | Mucous membranes dry. Oropharynx clear. No meningismus. Pupils 3 mm, equal, reactive. |
| Cardiovascular | Tachycardic, regular rhythm. No murmurs, rubs, or gallops. Capillary refill 3 seconds. Extremities cool. |
| Respiratory | Tachypneic. Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. |
| Abdomen | Soft, non-distended. Right costovertebral angle tenderness elicited. Mild suprapubic tenderness. No rebound, no guarding. Bowel sounds present. |
| Genitourinary | Deferred; urine sample obtained via straight catheter. |
| Skin | Warm, diaphoretic, intact. No rashes or pressure injuries. |
| Neurologic | As above under mental status. Moves all four extremities spontaneously and symmetrically. Reflexes 2+ throughout. |
See attached laboratory report. EKG: sinus tachycardia, no acute ischemic changes. CT abdomen/pelvis with contrast: findings consistent with right acute pyelonephritis; no obstructing calculus or abscess.
Two large-bore peripheral IVs placed. Blood cultures x2 sets drawn peripherally at 20:05 prior to antibiotics. Initial labs including lactate drawn at 19:50; lactate resulted at 3.8 mmol/L. A 30 mL/kg Lactated Ringer's bolus (2040 mL for 68 kg) was initiated at 20:12. Ceftriaxone 2 g IV was administered at 20:25, within the one-hour target from arrival. CBC, comprehensive metabolic panel, urinalysis with reflex culture, procalcitonin, CRP, coagulation panel, and serial lactate were sent. CT abdomen/pelvis with contrast demonstrated findings consistent with right acute pyelonephritis without obstructing stone or abscess. EKG showed sinus tachycardia without acute ischemic changes. A repeat lactate at 22:50 was 2.4 mmol/L (still above 2 mmol/L after completion of the 30 mL/kg crystalloid bolus). Despite completion of the full 30 mL/kg crystalloid resuscitation, the patient remained hypotensive with MAP persistently below 65. Norepinephrine was initiated at 23:25, titrated for MAP >=65, and a right internal jugular central venous catheter was placed for vasopressor administration. Critical care was consulted and the patient was transferred to the ICU at 23:55 in septic shock.
71-year-old woman with type 2 diabetes, CKD stage 3, and hypertension presenting with altered mental status, fever, tachycardia, hypotension, right CVA tenderness, and documented pyuria, with CT consistent with right pyelonephritis. Septic shock from a urinary source: required norepinephrine for MAP <65 despite 30 mL/kg crystalloid; repeat lactate 2.4 after fluids. Admit to ICU.
Rationale: Suspected/confirmed urinary-source infection with acute organ dysfunction — vasopressor requirement for hemodynamics, acute rise in creatinine (2.4 from baseline 1.3), and altered mentation (GCS 13). Lactate >2 after 30 mL/kg crystalloid PLUS vasopressor requirement satisfies the septic-shock definition.
Plan: Norepinephrine titrated to MAP >=65 via right IJ central line. Continue ceftriaxone 2 g IV q24h pending cultures. Serial lactates. Strict I/O and Foley catheter. ICU-level monitoring.
Rationale: Creatinine 2.4 mg/dL on a baseline of 1.3 (1.85x baseline at admission). Sepsis-associated; monitor for KDIGO staging.
Plan: Hold metformin and lisinopril. Renally dose all medications. Avoid nephrotoxins. Trend creatinine and urine output.
Rationale: CT abdomen/pelvis with findings of right pyelonephritis; UA with large leukocyte esterase, positive nitrite, >100 WBC/hpf.
Plan: Continue ceftriaxone; narrow per susceptibilities.
Plan: Hold home metformin. Insulin sliding scale. Monitor glucose.
Plan: Hold outpatient antihypertensives in the setting of shock; resume when off pressors and hemodynamically stable.
Plan: Expect improvement with source control and hemodynamic stabilization; reorientation and safety precautions.
ADMIT to ICU under Internal Medicine / Hospitalist Service (Dr. Okafor) with Critical Care co-management (Dr. Halvorsen). Diagnosis: Sepsis due to E. coli with severe sepsis and septic shock (A41.51 / R65.21) secondary to right acute pyelonephritis. Condition: Critical. Vitals q1h. Continuous cardiac and pulse-oximetry monitoring. Strict I/O, Foley catheter. Norepinephrine infusion titrate 2-10 mcg/min for MAP >=65 via right IJ CVC. Lactated Ringer's at 100 mL/hr after bolus complete. Ceftriaxone 2 g IV q24h. DVT prophylaxis: pneumatic compression while on pressors. PPI: pantoprazole 40 mg IV daily. Diet: NPO until further notice. Labs: CBC, BMP, lactate q6h x24h; repeat creatinine; blood cultures x2 (already drawn). Code status: Full code per discussion with patient and husband.