Pneumonia in the critically ill hospitalized patient.

Dr Douglas Schultz: A 59-year-old white man with a three-,nonth history of systemic lupus erytheinatost,s and a history of insulindependent diabetes mellitus was admitted to the hospital with a three-day history offever to 38.8#{176}C and dysuria. Evaluation revealed a urinary tract infection with F coli and benign prostatic hypertrophy. One month later, the patient underwent transi,rethral resection ofthe prostate. On the fourth postoperative da) he developed fever to 39.4#{176}C, shortness of breath, weakness, confusion, and reported a slightly productive cough. His medications at the time included prednisone, 10 mg dail); and NPII insulin, 20 units sulxs,taneosislv daily. On initial examination, the patient was found to be mildly short ofbreath with a respiratory rate of32, blood pressure of 120/76 mm 1-1g. and a temperature of 39.3#{176}Crectall}: His on1y remarkal)le physical findings were crackles ii the posterior aspect of the right lung in the upper two-thirds ofthe chest. The remainder ofhis lung examination was unremarkable and flO new extrapulmonary findings were noted. Laboratory evaluation showed a white blood cell count of 8,600 with 85 percent po1 s and 10 percent bands. Blood glucose was 347 mg/(1l and arterial blood gases, while breathing room air, showed a p11 of 7.4, Pco 38 mm 11g. and Pu, of 56 mm 11g. A chest radiograph (Fig 1) showed a right i,pper lobe infiltrate. Sputum was evaluated b Gram stain and showed copious white blood cells with (;ram-negative rods. Sputum md blood cultures were obtained. The remainder of the lalxratory data was i,,iremarkahle. The patient was treated with a presumptive diagnosis of u)5(x’omial Gram-negative pneumonia and therapy included intravenous hydration, oxygen via a 40 Iwrcent Venti-mask, aH(l iI1traveIu)L s ceftazidime. lii addition, the patient received appropriate increases in steroid therapy for stress, and insulin coverage for hyperglycemia. Two days later, the patient was fom nd to he more short of breath and he was transferred to Winthrop-University hospitals intensive care m nit for further care. On arrival, the patient had a hhxxl pressure of 70 palpable. Arterial blood gases, with the p itieiit breathing via 40 percent Venti-mask, showed a p11 of7.36, Pco = 22