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INDICATIONS
This 49-year-old female presents complaining of elevated temperature for 3 days accompanied by vomiting over that same time frame. She was evaluated here in the emergency department within the preceding few days and presents at this time with a temperature of a 105.3, pulse of 120, respiratory rate 26, and blood pressure 140/76.
Physical assessment revealed there was no nuchal rigidity. Pharynx was clear. Heart rate regular. Abdomen was soft. Rectal exam deleted. Lower extremities free of any significant pretibial edema. There was bilateral negative Homans.
PLAN WHILE IN THE EMERGENCY DEPARTMENT
Multiple diagnostic studies were performed including CBC. She had a white blood count of 9900, 74 segs, 9 bands, hemoglobin 11.3, glucose 121, sodium 133, potassium 3.2.
Catheter urinalysis showed 3+ bacteria, 40 to 50 white blood cells, 60 to 70 red blood cells, specific gravity of 1.025.
IMPRESSION
Sepsis, rule out pyelonephritis.
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