Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 1: Sepsis from Urinary Source with Rapid Deterioration
Clinical Presentation
Patient Demographics: 76-year-old female
Chief Complaint: "She's suddenly gotten much worse" - called by the nurse
Clinical Context: You are the sub-intern covering the medicine floor at 2 PM. Mrs. Johnson was admitted yesterday for a urinary tract infection and was started on oral ciprofloxacin. The nurse pages you because the patient "looks different" and her vital signs have changed.
History of Present Illness: Mrs. Johnson is a 76-year-old female with a history of type 2 diabetes mellitus, benign prostatic hyperplasia equivalent (urinary retention requiring intermittent catheterization), and mild dementia who was admitted 18 hours ago for dysuria, increased urinary frequency, and low-grade fever. She was started on ciprofloxacin 500 mg PO BID. This morning, she appeared comfortable and was eating breakfast. However, over the past 2 hours, the nurse notes she has become increasingly confused, less responsive, and her vital signs have deteriorated.
Past Medical History:
- Type 2 diabetes mellitus
- Dementia (mild, baseline oriented to person and place)
- Recurrent urinary tract infections
- Hypertension
- Osteoporosis
Medications on Admission:
- Ciprofloxacin 500 mg PO BID (started yesterday)
- Metformin 500 mg BID
- Lisinopril 10 mg daily
- Donepezil 10 mg daily
- Calcium/Vitamin D
Physical Examination at Time of Call:
- Vital Signs: Temperature 39.2C, HR 112 bpm, BP 88/52 mmHg, RR 26/min, SpO2 94% on room air
- General: Acutely ill-appearing, drowsy but arousable, confused
- Cardiovascular: Tachycardic, regular rhythm, warm extremities with bounding pulses
- Lungs: Clear to auscultation
- Abdomen: Soft, mild suprapubic tenderness
- Neurologic: Oriented to person only (baseline: person and place), following simple commands
Recognition of Deterioration
Early Warning Signs Identified:
- Temperature spike from 37.8C to 39.2C
- Heart rate increase from 82 to 112 bpm
- Blood pressure drop from 124/76 to 88/52 mmHg
- New confusion beyond baseline
- Respiratory rate increase from 16 to 26/min
- Nursing concern about appearance
Modified Early Warning Score (MEWS):
- Respiratory rate (26): 2 points
- Heart rate (112): 2 points
- Systolic BP (88): 2 points
- Temperature (39.2): 1 point
- AVPU (Confused/Verbal): 1 point
- Total MEWS: 8 (Critical - immediate escalation required)
Immediate Actions (ABCDE Approach)
Airway: Patent, patient speaking Breathing: Tachypneic but adequate; apply 2L NC to maintain SpO2 > 94% Circulation: Hypotensive - establish second IV access, initiate fluid bolus Disability: Altered mental status - check fingerstick glucose (result: 142 mg/dL) Exposure: No rashes, wounds appear clean
Stabilization and Escalation
Immediate Interventions:
- Call for help - notified senior resident and attending
- IV normal saline 30 mL/kg bolus (approximately 2L for 68 kg patient)
- Obtain blood cultures x 2 (before antibiotics if possible)
- Broaden antibiotics: Ceftriaxone 2g IV + Metronidazole 500 mg IV
- Obtain stat labs: CBC, CMP, lactate, blood gas, urinalysis
- Place Foley catheter for urine output monitoring
- Continuous pulse oximetry
Escalation Communication (SBAR):
"Dr. Martinez, this is [name], the sub-intern. I'm calling about Mrs. Johnson in room 412.
Situation: She's acutely deteriorating with septic shock from a urinary source.
Background: She's a 76-year-old admitted yesterday for UTI on oral cipro. She has diabetes and mild dementia.
Assessment: Her BP dropped to 88/52, heart rate is 112, temp spiked to 39.2, and she's now confused beyond her baseline. I'm concerned about urosepsis with inadequate source control.
Recommendation: I've started a fluid bolus, obtained cultures, and I'd like to broaden antibiotics to ceftriaxone and metronidazole. Should we consider ICU transfer if she doesn't respond to fluids?"
Inpatient Workup Results
Laboratory Studies:
- WBC 18,400/uL with 15% bands (left shift)
- Hemoglobin 11.2 g/dL
- Platelets 142,000/uL
- Sodium 134 mEq/L, Potassium 4.8 mEq/L
- BUN 42 mg/dL, Creatinine 2.1 mg/dL (baseline 1.0)
- Lactate 4.2 mmol/L
- Procalcitonin 8.6 ng/mL
- Urinalysis: Large leukocyte esterase, positive nitrites, >100 WBC/hpf, many bacteria
Imaging:
- CT abdomen/pelvis with contrast: Left hydronephrosis with 8mm obstructing ureteral stone, perinephric stranding concerning for pyelonephritis
Diagnosis
Primary Diagnosis: Septic shock secondary to obstructive pyelonephritis (urosepsis)
qSOFA Score: 3 (altered mental status, SBP < 100, RR > 22) SOFA Score: Elevated (renal dysfunction, altered mental status)
Treatment Plan
Immediate (Hour 1):
- Complete 30 mL/kg fluid resuscitation
- Antibiotics administered within 1 hour of recognition
- Urology consultation for emergent ureteral stent placement
- Transfer to ICU for close monitoring
If fluid-refractory (MAP < 65 after 2L):
- Initiate norepinephrine via central line
- Arterial line for continuous BP monitoring
Ongoing Care:
- Repeat lactate in 2-4 hours (goal: lactate clearance)
- Monitor urine output (goal: > 0.5 mL/kg/hr)
- Daily assessment for de-escalation once cultures finalize
- Hold metformin and ACE inhibitor given AKI
Clinical Image
Image Description: While this patient's chest X-ray was clear, severe sepsis can progress to acute respiratory distress syndrome (ARDS) with bilateral infiltrates. This image demonstrates the pulmonary findings that may develop in critically ill patients with sepsis.
Image Source: Wikimedia Commons - "Chest X-ray in influenza and H. influenzae"
- URL: https://commons.wikimedia.org/wiki/File:Chest_X-ray_in_influenza_and_Haemophilus_influenzae_-_annotated.jpg
- License: Creative Commons CC0 1.0 Universal Public Domain Dedication
- Author: Mikael Haggstrom, M.D.