Samir Sultan, DO
Banner University Medical Center Phoenix
Phoenix, AZ
History of Present Illness
The patient is a 32-year-old woman who presented with flank pain for 3 days to an outside hospital. She was diagnosed with pyelonephritis and begun on ceftriaxone. She was discharged against medical advice on cephalexin.
She returned to the same hospital 3 days later by ambulance with labored breathing and weakness and was emergently intubated. She was transferred for ventilator management and respiratory failure.
Past Medical History
She has a long history of poorly controlled diabetes mellitus.
Physical Examination
She is orally intubated and sedated.
Vitals: Temperature - 100.9º F, Blood Pressure - 117/75 mm Hg, Heart Rate - 148 beats per minute, Respiratory Rate - 31 breaths/min, SpO2 - 88 % on assist control of 30, tidal volume of 350 mL, PEEP 15, and an FiO2 100%.
There is scatted rhonchi and rales but the remainder of the physical examination is unremarkable.
Radiography
Her admission portable chest X-ray is shown in Figure 1.
Figure 1. Admission portable AP of the chest.
Which of the following should be ordered as part of her initial work-up? (Click on the correct answer to proceed to the second of five panels).
- Administer broad spectrum antibiotics
- Blood and urine cultures
- Rapid influenza test
- 1 and 3
- All of the above
Cite as: Sultan S. December critical care case of the month. Southwest J Pulm Crit Care. 2015;11(6):246-51. doi: http://dx.doi.org/10.13175/swjpcc147-15 PDF