Diagnose It Answer — April 20, 2026

85-year-old male nursing home resident transferred to the ED with altered mental status and confusion that developed acutely this morning. He is unable to provide history but his transfer paperwork notes he became agitated, refused to eat, and would not get out of bed. Staff observed him wincing when repositioned and noticed strong-smelling urine. He is moaning and appears uncomfortable.

History of benign prostatic hyperplasia (BPH), type 2 diabetes, and dementia (baseline MMSE 18/30). He has a chronic indwelling urinary catheter due to urinary retention from BPH. Per facility records, the catheter was last changed 6 weeks ago. He had a UTI treated with oral antibiotics approximately 8 weeks ago. Current medications include tamsulosin, metformin, and donepezil.

BP 96/58 mmHg, HR 122 bpm, RR 24 breaths/min, Temp 39.2°C (102.6°F), SpO2 94% on room air. Patient is confused beyond his baseline — minimally responsive to voice, localizing to pain only. Skin flushed and warm. Capillary refill 3 seconds. Bladder scan shows 480mL despite indwelling catheter (catheter likely occluded).

SOFA score 5 — meets criteria for sepsis with organ dysfunction. Two large-bore IVs placed; 30 mL/kg normal saline bolus initiated per Sepsis-3 bundle. Indwelling catheter removed and replaced — thick, cloudy, malodorous urine with sediment immediately drains. Urine culture and sensitivity, blood cultures x2, and serum lactate drawn before antibiotics. Piperacillin-tazobactam IV initiated empirically within 45 minutes of arrival. Urology and infectious disease consulted.

Urinalysis: cloudy, amber; nitrites positive; leukocyte esterase 3+; >100 WBCs/hpf; many bacteria on microscopy. Urine culture pending. WBC 22,100/µL (85% neutrophils, 14% bands). Lactate 3.8 mmol/L (elevated — tissue hypoperfusion). Creatinine 2.4 mg/dL (baseline 1.0 — acute kidney injury). Procalcitonin 28 ng/mL. Blood glucose 298 mg/dL. Renal ultrasound: mild bilateral hydronephrosis; no abscess or stone identified.