Suspect most likely infectious in etiology to patient’s symptoms.

Most likely pulmonary source versus urinary source given lung exam as above as well as cough with yellow sputum versus urinary source given history of BPH and patient at previous breast her risk of urinary tract infection.

Will administer ceftriaxone and azithromycin empirically. Patient denies recent hospitalization therefore healthcare associated pneumonia antibiotics not indicated. 

 

Labs and lactate and cultures pending. IV fluids initiated. Patient is hemodynamically stable. Is febrile and given antipyretic however does not meet other SIRS criteria.

Considered broad range of sources:

Consider GI source however given no GI symptoms and abdominal exam is benign, this is sufficiently unlikely.

Considered skin sores however no lesions seen on skin exam.

Considered HEENT source however no rhinorrhea, pharyngitis or ear pain suggestive of bacterial infection on HEENT system.

Considered urinary source, UA pending.

Severity: Given the patient is hemodynamically stable, has a normal lactate and only meets 1 the SIRS criteria, the patient does not meet criteria for sepsis at this time.