Severe sepsis from pneumonia with kidney injury

EXAM: Chest radiograph, AP portable INDICATION: Fever, hypotension, cough. FINDINGS: Dense consolidation in the right lower lobe with air bronchograms. No pleural effusion or pneumothorax. Heart size within normal limits. Coronary stent noted. IMPRESSION: Right lower lobe pneumonia.

CC: Fever, cough, weakness. HPI: 72M with T2DM, HTN and CAD s/p PCI (2021) brought by wife for 3 days of cough with rusty sputum, fever, rigors and decreased oral intake; today too weak to stand. Urinating less. No chest pain. Vitals: T 39.1 C, HR 124, BP 88/50, RR 28, SpO2 94% RA. Exam: Ill-appearing, alert and oriented x3. Dry mucosa. Coarse crackles R base. Tachycardic. Cool extremities, cap refill 3 s. Labs: WBC 19.4 (bands 12%), Hgb 13.8, Plt 162. Na 135, K 4.8, HCO3 18, BUN 46, Cr 2.4 (baseline 0.9, 05/2026), Glu 246. Lactate 3.4. Procalcitonin 8.6. CXR: RLL consolidation. Assessment/Plan: 1. Sepsis due to RLL pneumonia with hypotension, lactate 3.4 and AKI. Blood cx x2, then cefepime 2 g IV + azithromycin 500 mg IV. LR 30 mL/kg (2.4 L). BP 112/64 after bolus, no vasopressors needed. Repeat lactate. Dispo: Admit to step-down.

HISTORY AND PHYSICAL HPI: As per ED. After 2.4 L LR, MAP 78, HR 104, UOP 40 mL/h. Repeat lactate 2.1. PMH: T2DM (A1c 7.2%, no known complications). HTN. CAD s/p DES to LAD 2021, no angina since; on aspirin and high-intensity statin. Meds: metformin 1000 mg BID, lisinopril 10 mg daily, atorvastatin 80 mg daily, aspirin 81 mg daily. Social: Retired machinist. Never smoker. Exam: T 38.3, HR 104, BP 116/66, RR 22, SpO2 95% RA. Alert, oriented. Crackles R base. No edema. Assessment/Plan: 1. Severe sepsis due to RLL community-acquired pneumonia, with acute organ dysfunction (AKI). No septic shock - BP fluid responsive, no vasopressors. Cefepime + azithromycin; f/u cultures; lactate q6h until normal. 2. Acute kidney injury - Cr 2.4 from baseline 0.9, prerenal from sepsis and volume depletion. IV fluids, hold lisinopril and metformin, avoid nephrotoxins, strict I/O. 3. T2DM - hold metformin; glargine 10 units + correction scale. 4. HTN - hold lisinopril for AKI and soft BP. 5. CAD s/p PCI - continue aspirin 81 mg daily and atorvastatin 80 mg.

Step-down. Sepsis reassessment completed after 30 mL/kg bolus: MAP 76-82, HR 100-106, no vasopressors required. UOP 35-50 mL/h via urinal. A&O x3, follows commands. SpO2 95% RA. Febrile 38.4 at 04:00, acetaminophen given. Cefepime second dose hung on time. Fingerstick 212, correction insulin per scale. Wife updated by phone.

Lactate: 09/10 22:30 3.4; 09/11 01:50 2.1; 09/11 08:00 1.4 Creatinine: 09/10 2.4; 09/11 2.1; 09/12 1.6; 09/13 1.2 WBC: 09/10 19.4; 09/12 13.0; 09/13 10.1 Blood cultures x2 (09/10): no growth at 48 h. Sputum culture: normal respiratory flora. Urine Legionella and pneumococcal antigens: negative.

HOSPITAL DAY 3 S: Eating, walked with PT. Cough improving. O: T 37.2, HR 86, BP 128/74, SpO2 96% RA. UOP adequate. Assessment/Plan: 1. Severe sepsis due to RLL pneumonia - resolving, lactate normal, cultures negative. Narrow to ceftriaxone; azithromycin completed. 2. AKI - improving, Cr 1.2. Continue holding lisinopril and metformin until Cr at baseline. 3. T2DM - BG 130-180 on basal/correction. 4. CAD, HTN - stable. Transfer to med-surg.

DISCHARGE SUMMARY Admit: 09/10/2026 Discharge: 09/15/2026 Disposition: Home with wife DISCHARGE DIAGNOSES: 1. Severe sepsis due to RLL community-acquired pneumonia, without septic shock 2. Acute kidney injury due to sepsis, resolved 3. Type 2 diabetes mellitus 4. Hypertension 5. Coronary artery disease s/p PCI, on aspirin HOSPITAL COURSE: Presented with fever, hypotension responsive to fluids, lactate 3.4 and Cr 2.4 from RLL pneumonia. Treated with IV fluids and antibiotics; never required vasopressors. Lactate normalized within 10 h; Cr down to 1.0 by 09/15. Cultures negative. Transitioned to oral cefpodoxime to complete 7 days. Metformin and lisinopril resumed at discharge. FOLLOW-UP: PCP in 1 week with BMP.