Henry Luedy, MD
Clement U. Singarajah, MD
Phoenix VA Medical Center
Phoenix, AZ
History of Present Illness
An 85 year old patient was admitted with hypotension and respiratory failure. He was intubated shortly after arrival and mechanical ventilation was begun. Fluids and vasopressors were begun for his hypotension.
PMH, SH, FH
His past medical history included peripheral vascular disease, abdominal aortic aneurysm repair, type 2 diabetes mellitus, hypertension, alcohol use, coronary artery disease, chronic obstructive pulmonary disease and hyperlipidemia.
Physical Examination
His vital signs were a temperature of 98.6 degrees F, heart rate 110 beats/min, respiratory rate 14 breaths per minute while intubated and receiving mechanical ventilation, and BP of 95/65 mmHg on vasopressors.
He was sedated. Lungs were clear and the heart had a regular rhythm without murmur or gallop. Abdominal examination was unremarkable and neurologic exam was limited because of sedation but without localizing signs. Plantar reflexes were down-going.
Admission Laboratory
Significant initial laboratory findings included a white blood cell count of 21,000 cells/μL, blood lactate level of 10 mmol/L and creatinine of 12 mg/dL. Urinanalysis showed pyuria and was positive for nitrates. At this time which of the following are diagnostic possibilities?
Reference as: Luedy H, Singarajah CU. October 2012 critical care case of the month. Southwest J Pulm Crit Care 2012;5:179-85. PDF