Severe E. coli sepsis, shock explicitly absent

CC: confusion, fever. HPI: 77 y/o F with T2DM, HTN, HLD brought by daughter for 1 day of confusion and fever after 3 days of dysuria and frequency. Daughter reports she was "talking nonsense" this AM and did not recognize her granddaughter. Decreased PO intake x 2 days. Vitals on arrival: T 39.2 C, HR 118, RR 24, BP 98/56 (MAP 70), SpO2 95% RA. Exam: Ill-appearing, oriented to self only, inattentive. Dry MM. Suprapubic tenderness, + R CVA tenderness. Lungs clear. Labs: WBC 18.6 (bands 12%), Hgb 12.4, Plt 162. Na 136, K 4.4, HCO3 17, BUN 41, Cr 2.3 (baseline 0.8, 04/2026). Lactate 4.2. Glucose 248. UA: large LE, nitrite +, > 100 WBC/hpf, many bacteria. ED course: Sepsis alert. Blood cx x2, urine cx. 30 mL/kg LR (2 L) over 1 h. Ceftriaxone 2 g IV. Concern for septic shock on arrival; after fluids MAP 74-78, never < 65, no vasopressors required. Impression: Severe sepsis, UTI source. Admit to step-down.

HISTORY AND PHYSICAL HPI: 77F with T2DM (metformin), HTN, HLD with 3 days dysuria, 1 day fever and acute confusion. Met sepsis criteria in ED with lactate 4.2, Cr 2.3 from baseline 0.8, and acute encephalopathy. Received 30 mL/kg LR. PMH: T2DM (A1c 7.6%), HTN, HLD. Meds: metformin 500 mg BID, losartan 50 mg, atorvastatin 20 mg. Exam: T 38.4, HR 102, BP 108/62 (MAP 77), RR 20. Oriented to self and place only, inattentive on months-backward test. No focal deficits, no meningismus. + R CVA tenderness. ASSESSMENT/PLAN: 1. Severe sepsis due to UTI (likely early pyelonephritis), with acute organ dysfunction (AKI, lactic acidosis, encephalopathy). No signs of septic shock - MAP > 65 after initial fluid resuscitation without pressors. Ceftriaxone 2 g daily; f/u cultures. Repeat lactate in 4 h. Additional LR 500 mL boluses PRN MAP < 65. 2. AKI due to sepsis/volume depletion - Cr 2.3 from 0.8. Hold losartan and metformin. IVF, strict I/O, renally dose meds. 3. Acute metabolic encephalopathy due to sepsis/UTI - no sedating meds, delirium precautions, frequent reorientation. CT head not indicated (nonfocal, clear infectious source). 4. T2DM - hold metformin; basal-bolus insulin while inpatient. 5. HTN - hold losartan given soft BP. 6. HLD - continue statin. Code: Full. Step-down.

Lactate: 09/12 07:10 4.2; 09/12 12:05 2.4; 09/12 18:00 1.9; 09/13 05:50 1.3. Creatinine: 2.3 -> 1.9 -> 1.4 (09/13). WBC 18.6 -> 14.2. Plt 162 -> 151. Urine culture (09/12): > 100,000 CFU/mL Escherichia coli, susceptible to ceftriaxone, cefazolin, TMP-SMX; resistant to ampicillin. Blood cultures (09/12): 2/2 bottles Escherichia coli (same susceptibility pattern).

S: More alert, knows she is in hospital, still mildly inattentive. Eating some breakfast. O: Tmax 38.0, HR 90, BP 122/68, MAP 86 off fluids. Lactate cleared 1.3. Cr 1.4. Blood and urine cx: E. coli. A/P: 1. Severe sepsis due to E. coli UTI with E. coli bacteremia - no septic shock at any point; never required vasopressors. Continue ceftriaxone; plan 10-14 day total course for bacteremic UTI. Transfer to med-surg. 2. AKI - improving, Cr 2.3 -> 1.4. 3. Acute metabolic encephalopathy - improving with treatment of infection. 4. T2DM - BG 160-220, titrate insulin. 5. HTN - continue holding losartan. 6. HLD - statin.

DISCHARGE SUMMARY Admit 09/12/2026 - Discharge 09/17/2026. Home with daughter, home health RN. Principal diagnosis: Sepsis due to E. coli (blood and urine cultures), urinary source. Secondary diagnoses: Severe sepsis with acute organ dysfunction (AKI, acute metabolic encephalopathy) - without septic shock. Urinary tract infection, E. coli. Acute kidney injury, resolved. Acute metabolic encephalopathy, resolved. Type 2 diabetes mellitus. Hypertension. Hyperlipidemia. Hospital course: Presented with fever, confusion, dysuria, lactate 4.2 and Cr 2.3. Fluid resuscitated with prompt MAP response; no septic shock, no vasopressors. Treated with IV ceftriaxone, transitioned to PO cefpodoxime 09/16 per susceptibilities. Lactate normalized within 24 h; Cr 0.9 at discharge. Mental status back to baseline per daughter by HD3. Discharge meds: cefpodoxime 200 mg BID to complete 14 days total; resume metformin 09/19 if PO intake good; resume losartan at PCP visit; atorvastatin 20 mg. Follow-up: PCP 1 week with BMP.